Healthcare Provider Details

I. General information

NPI: 1982525820
Provider Name (Legal Business Name): OMORETTE KIRLEW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2026
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1206 SW MARMORE AVE
PORT ST LUCIE FL
34953-5016
US

IV. Provider business mailing address

1206 SW MARMORE AVE
PORT ST LUCIE FL
34953-5016
US

V. Phone/Fax

Practice location:
  • Phone: 561-774-1487
  • Fax: 561-774-1487
Mailing address:
  • Phone: 561-774-1487
  • Fax: 561-774-1487

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number11045750
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: