Provider Demographics
NPI:1093814964
Name:MASSENGALE, JILL (ARNP)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:MASSENGALE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13000 BRUCE B DOWNS BLVD
Mailing Address - Street 2:(117)
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-4745
Mailing Address - Country:US
Mailing Address - Phone:813-972-2000
Mailing Address - Fax:813-903-4876
Practice Address - Street 1:11663 COUNTRYWAY BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-2739
Practice Address - Country:US
Practice Address - Phone:813-891-6310
Practice Address - Fax:813-891-6889
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2009-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9184657363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLARNP9184657OtherSTATE LINENCE
FL1093814964OtherNPI