Basic Information
| Provider Information | |||||||||
| NPI: | 1700112786 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOUWHUIS | ||||||||
| FirstName: | GEORGETTE | ||||||||
| MiddleName: | FARNHAM | ||||||||
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| Credential: | A.R.N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1839 CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337138900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273221054 | ||||||||
| FaxNumber: | 7278217213 | ||||||||
| Practice Location | |||||||||
| Address1: | 6640 78TH AVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | PINELLAS PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33781 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7275188660 | ||||||||
| FaxNumber: | 7275188662 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2009 | ||||||||
| LastUpdateDate: | 04/28/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | ARNP 3239142 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 025010200 | 05 | FL | MEDICAID |