Provider Demographics
NPI:1508151838
Name:SODERBERG, REGINA L (ARNP)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:L
Last Name:SODERBERG
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:REGINA
Other - Middle Name:
Other - Last Name:LYDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-C
Mailing Address - Street 1:8619 AMEN CORNER PL
Mailing Address - Street 2:
Mailing Address - City:PALMETTO
Mailing Address - State:FL
Mailing Address - Zip Code:34221-8483
Mailing Address - Country:US
Mailing Address - Phone:727-543-6277
Mailing Address - Fax:941-216-3703
Practice Address - Street 1:3914 E STATE ROAD 64
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208-9059
Practice Address - Country:US
Practice Address - Phone:941-216-3800
Practice Address - Fax:941-216-3703
Is Sole Proprietor?:No
Enumeration Date:2011-06-15
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9165396363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003633800Medicaid