Provider Demographics
NPI:1396010229
Name:IM, VA (ARNP-C)
Entity Type:Individual
Prefix:MRS
First Name:VA
Middle Name:
Last Name:IM
Suffix:
Gender:F
Credentials:ARNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 10TH ST N STE 1E
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33705-1407
Mailing Address - Country:US
Mailing Address - Phone:727-824-3120
Mailing Address - Fax:727-824-8313
Practice Address - Street 1:620 10TH ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33705-1407
Practice Address - Country:US
Practice Address - Phone:727-824-3120
Practice Address - Fax:727-824-8313
Is Sole Proprietor?:No
Enumeration Date:2012-03-09
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9230763363LA2200X
FLAPRN9230763363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL016891600Medicaid