Provider Demographics
NPI:1326556200
Name:SOUTHERN PRACTITIONER
Entity Type:Organization
Organization Name:SOUTHERN PRACTITIONER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:PRINCE
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:850-434-0077
Mailing Address - Street 1:904 N 75TH AVE
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32506-3820
Mailing Address - Country:US
Mailing Address - Phone:850-434-0077
Mailing Address - Fax:850-434-0220
Practice Address - Street 1:15 W MAXWELL ST
Practice Address - Street 2:STE 148
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501-1717
Practice Address - Country:US
Practice Address - Phone:850-434-0077
Practice Address - Fax:850-434-0220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-13
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9167682363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL111684900Medicaid