Provider Demographics
NPI:1609595248
Name:MACDOUGALL, TINA LOUISE (APRN, FNP-BC)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:LOUISE
Last Name:MACDOUGALL
Suffix:
Gender:F
Credentials:APRN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2115 SE LENNARD RD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-4742
Mailing Address - Country:US
Mailing Address - Phone:771-335-1812
Mailing Address - Fax:
Practice Address - Street 1:2115 SE LENNARD RD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-4742
Practice Address - Country:US
Practice Address - Phone:772-335-1812
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-25
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11020684363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily