Basic Information
Provider Information | |||||||||
NPI: | 1639479900 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BLOODWORTH | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP-BC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | FAZIO | ||||||||
OtherFirstName: | JENNIFER | ||||||||
OtherMiddleName: | MARIE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1137 | ||||||||
Address2: |   | ||||||||
City: | MELBOURNE | ||||||||
State: | FL | ||||||||
PostalCode: | 329021137 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3219529696 | ||||||||
FaxNumber: | 3219527937 | ||||||||
Practice Location | |||||||||
Address1: | 5270 BABCOCK ST NE | ||||||||
Address2: | SUITE 1 | ||||||||
City: | PALM BAY | ||||||||
State: | FL | ||||||||
PostalCode: | 329058630 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3217225959 | ||||||||
FaxNumber: | 3217225960 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/02/2010 | ||||||||
LastUpdateDate: | 08/18/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | ARNP9310812 | FL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 003241600 | 05 | FL |   | MEDICAID |