Provider Demographics
NPI:1376707562
Name:BOODHOO, JACQUELINE VANITA (APRN)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:VANITA
Last Name:BOODHOO
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 1:1717 S ORANGE AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-2944
Mailing Address - Country:US
Mailing Address - Phone:321-841-4344
Mailing Address - Fax:321-843-1753
Practice Address - Street 1:1717 S ORANGE AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2944
Practice Address - Country:US
Practice Address - Phone:321-841-4344
Practice Address - Fax:321-843-1753
Is Sole Proprietor?:No
Enumeration Date:2008-07-16
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN221717363LA2200X, 163WG0100X
FLAPRN11013211363LA2200X
CA645901163W00000X
CA17544363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
No163WG0100XNursing Service ProvidersRegistered NurseGastroenterology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner