Provider Demographics
NPI:1265042683
Name:PROFFITT, REGINA
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:PROFFITT
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 1:2068 HEALTH CARE AVE
Mailing Address - Street 2:
Mailing Address - City:NAVARRE
Mailing Address - State:FL
Mailing Address - Zip Code:32566-2901
Mailing Address - Country:US
Mailing Address - Phone:850-930-5878
Mailing Address - Fax:
Practice Address - Street 1:5243 SPRING ST
Practice Address - Street 2:
Practice Address - City:PACE
Practice Address - State:FL
Practice Address - Zip Code:32571-2828
Practice Address - Country:US
Practice Address - Phone:419-512-2941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-01
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH344508163W00000X
FL9537319163W00000X
FL11008482363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse