=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376388215
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMINA MARIE DEFALCO APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/01/2024
-----------------------------------------------------
Last Update Date | 03/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1300 N LAWNWOOD CIR
-----------------------------------------------------
City | FORT PIERCE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34950-4884
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-302-3977
-----------------------------------------------------
Fax | 877-229-5205
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 915 SW BUTTERFLY TER
-----------------------------------------------------
City | PORT ST LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34953-1526
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-342-2715
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 11033594
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------