Provider Demographics
NPI:1144789843
Name:VIRGILE, FAUSTA MORTIMER (APRN)
Entity Type:Individual
Prefix:MRS
First Name:FAUSTA
Middle Name:MORTIMER
Last Name:VIRGILE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6640 DAHLIA DRIVE
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33023
Mailing Address - Country:US
Mailing Address - Phone:954-496-0020
Mailing Address - Fax:
Practice Address - Street 1:6640 DAHLIA DRIVE
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33023
Practice Address - Country:US
Practice Address - Phone:954-496-0020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-13
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11001603363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily