Healthcare Provider Details

I. General information

NPI: 1639461023
Provider Name (Legal Business Name): NYDIA M WHITAKER ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2011
Last Update Date: 12/25/2024
Certification Date: 12/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 VIRGINIA AVE STE 59B
FORT PIERCE FL
34982-5892
US

IV. Provider business mailing address

770 SW AVENS ST
PORT SAINT LUCIE FL
34983-8757
US

V. Phone/Fax

Practice location:
  • Phone: 772-577-6323
  • Fax:
Mailing address:
  • Phone: 772-380-3144
  • Fax: 877-733-7082

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11029135
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number000174302
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number000174301
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number000174300
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: