Healthcare Provider Details

I. General information

NPI: 1376707562
Provider Name (Legal Business Name): JACQUELINE VANITA BOODHOO APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2008
Last Update Date: 01/26/2024
Certification Date: 01/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 S ORANGE AVE
ORLANDO FL
32806-2944
US

IV. Provider business mailing address

1717 S ORANGE AVE
ORLANDO FL
32806-2944
US

V. Phone/Fax

Practice location:
  • Phone: 321-841-4344
  • Fax: 321-843-1753
Mailing address:
  • Phone: 321-841-4344
  • Fax: 321-843-1753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberRN221717
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAPRN11013211
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number645901
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code163WG0100X
TaxonomyGastroenterology Registered Nurse
License NumberRN221717
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number17544
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: