Provider Demographics
NPI:1629682331
Name:JEAN BAPTISTE, ALTAGRACE
Entity Type:Individual
Prefix:
First Name:ALTAGRACE
Middle Name:
Last Name:JEAN BAPTISTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5934 NW DOWELL CT
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-3831
Mailing Address - Country:US
Mailing Address - Phone:772-359-9187
Mailing Address - Fax:
Practice Address - Street 1:1404 S 28TH ST
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34947-6999
Practice Address - Country:US
Practice Address - Phone:772-293-0770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-01
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11008785363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily