Provider Demographics
NPI:1083816946
Name:WASHINGTON, REGINA IMARI (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MS
First Name:REGINA
Middle Name:IMARI
Last Name:WASHINGTON
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:MRS
Other - First Name:REGINA
Other - Middle Name:IMARI
Other - Last Name:SANDERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, MSN, GNP-BC
Mailing Address - Street 1:4645 PLANTATION OAKS BLVD
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32065-3652
Mailing Address - Country:US
Mailing Address - Phone:904-406-9399
Mailing Address - Fax:904-406-9413
Practice Address - Street 1:4645 PLANTATION OAKS BLVD
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32065-3652
Practice Address - Country:US
Practice Address - Phone:904-406-9399
Practice Address - Fax:904-406-9413
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-04
Last Update Date:2021-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF3405331363LG0600X
FLARNP9327002363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ17217Medicare UPIN