Provider Demographics
NPI:1114140860
Name:REICHERT, MARY JILL
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JILL
Last Name:REICHERT
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 1:1700 SE HILLMOOR DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-7539
Mailing Address - Country:US
Mailing Address - Phone:772-335-9600
Mailing Address - Fax:772-398-7951
Practice Address - Street 1:1700 SE HILLMOOR DR
Practice Address - Street 2:SUITE 200
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7539
Practice Address - Country:US
Practice Address - Phone:772-335-9600
Practice Address - Fax:772-398-7951
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2009-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3144302363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3089614000Medicaid
FLAK070YMedicare PIN
FLAK070ZMedicare PIN