Healthcare Provider Details

I. General information

NPI: 1043992514
Provider Name (Legal Business Name): TINYA C CLEMENTS APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2023
Last Update Date: 04/03/2024
Certification Date: 04/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1070 SW GATLIN BLVD
PORT ST LUCIE FL
34953
US

IV. Provider business mailing address

2190 SE GENOA ST
PORT ST LUCIE FL
34952-7333
US

V. Phone/Fax

Practice location:
  • Phone: 772-408-9434
  • Fax:
Mailing address:
  • Phone: 772-380-7897
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11027893
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: