Healthcare Provider Details

I. General information

NPI: 1225681398
Provider Name (Legal Business Name): ADAM BASTILLE FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2019
Last Update Date: 11/18/2025
Certification Date: 11/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2116 34TH ST S
ST PETERSBURG FL
33711-3224
US

IV. Provider business mailing address

701 94TH AVE N STE 250
ST PETERSBURG FL
33702-2448
US

V. Phone/Fax

Practice location:
  • Phone: 727-321-3854
  • Fax:
Mailing address:
  • Phone: 727-321-3854
  • Fax: 727-327-7670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP61679982
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11003356
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number11003356
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP61679982
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: