Provider Demographics
NPI:1053079129
Name:RODRIGUEZ, CHRISTIE FAYE
Entity Type:Individual
Prefix:
First Name:CHRISTIE
Middle Name:FAYE
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2465 SW CARPENTER STREET
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34984
Mailing Address - Country:US
Mailing Address - Phone:772-812-6838
Mailing Address - Fax:
Practice Address - Street 1:2465 SW CARPENTER STREET
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34984
Practice Address - Country:US
Practice Address - Phone:772-812-6838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-06
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11015917363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner