Healthcare Provider Details

I. General information

NPI: 1265042683
Provider Name (Legal Business Name): REGINA PROFFITT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2020
Last Update Date: 02/08/2022
Certification Date: 01/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5243 SPRING ST
PACE FL
32571-2828
US

IV. Provider business mailing address

2068 HEALTH CARE AVE
NAVARRE FL
32566-2901
US

V. Phone/Fax

Practice location:
  • Phone: 419-512-2941
  • Fax:
Mailing address:
  • Phone: 850-930-5878
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number344508
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number9537319
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11008482
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: