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General NPI Number Information
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NPI Number | 1326556200
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Entity Type | Organization
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Legal Business Name | SOUTHERN PRACTITIONER
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Dates
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Enumeration Date | 01/13/2018
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Last Update Date | 11/22/2022
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Provider Practice Location Address
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Address Line | 15 W MAXWELL ST STE 148
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City | PENSACOLA
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State | FL
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Zip | 32501-1717
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Country | US
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Telephone | 850-434-0077
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Fax | 850-434-0220
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Provider Business Mailing Address
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Address Line | 904 N 75TH AVE
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City | PENSACOLA
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State | FL
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Zip | 32506-3820
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Country | US
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Telephone | 850-434-0077
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Fax | 850-434-0220
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Authorized Official
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Title or Position | OWNER
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Name | JENNIFER PRINCE
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Credential | ARNP
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Telephone | 850-434-0077
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 9167682
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License Number State | FL
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