MEDICARE: MISS NINA LATASHA JERNIGAN FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	0024169403	VA

General Provider Information

NPI Number	:	1245523638
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS NINA LATASHA JERNIGAN FNP

Provider Business Mailing Address
First Line	:	924 SHORE DR
Second Line	:
City	:	NEWPORT NEWS
State	:	VA
Zip	:	23607-6435
Country	:	US
Telephone Number	:	757-503-3069
Fax Number	:

Provider Business Practice Location Address
First Line	:	1320 LASALLE AVE
Second Line	:
City	:	HAMPTON
State	:	VA
Zip	:	23669-3801
Country	:	US
Telephone Number	:	757-727-1820
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/18/2011
Last Update Date	:	09/22/2015

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