Healthcare Provider Details

I. General information

NPI: 1104790831
Provider Name (Legal Business Name): WINSTON HARDISON JR. RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2025
Last Update Date: 03/26/2026
Certification Date: 03/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

828 WALDEN BLVD SE
PALM BAY FL
32909-6683
US

IV. Provider business mailing address

828 WALDEN BLVD SE
PALM BAY FL
32909-6683
US

V. Phone/Fax

Practice location:
  • Phone: 321-302-3599
  • Fax:
Mailing address:
  • Phone: 321-302-3599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN11045332
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number9368976
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: