Provider Demographics
NPI:1144421462
Name:PRACTITIONER SERVICES, INC
Entity Type:Organization
Organization Name:PRACTITIONER SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:GRUBBS
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:239-878-1294
Mailing Address - Street 1:8931 FALCON POINTE LOOP
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-1474
Mailing Address - Country:US
Mailing Address - Phone:239-878-1294
Mailing Address - Fax:239-468-5878
Practice Address - Street 1:8931 FALCON POINTE LOOP
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-1474
Practice Address - Country:US
Practice Address - Phone:239-878-1294
Practice Address - Fax:239-468-5878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9189169363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK7363Medicare ID - Type Unspecified
FLP62377Medicare UPIN