Basic Information
| Provider Information | |||||||||
| NPI: | 1568558302 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRINCE | ||||||||
| FirstName: | LOURDES | ||||||||
| MiddleName: | ELENA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | ARNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | QUINONES-BURKE | ||||||||
| OtherFirstName: | LOURDES | ||||||||
| OtherMiddleName: | ELENA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 83 W MILLER ST | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328062028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3218415281 | ||||||||
| FaxNumber: | 4076489879 | ||||||||
| Practice Location | |||||||||
| Address1: | 83 W MILLER ST | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328062028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3218415281 | ||||||||
| FaxNumber: | 4076489879 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 11/16/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | ARNP1738622 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LW0102X | ARNP1738622 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health | 367A00000X | ARNP1738622 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 300688300 | 05 | FL | MEDICAID | ARNP1738622 | 01 | FL | MEDICAL LICENSE | OTHER |