Provider Demographics
NPI:1639461023
Name:WHITAKER, NYDIA M (ARNP)
Entity Type:Individual
Prefix:
First Name:NYDIA
Middle Name:M
Last Name:WHITAKER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:770 SW AVENS ST
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-8757
Mailing Address - Country:US
Mailing Address - Phone:772-380-3144
Mailing Address - Fax:877-733-7082
Practice Address - Street 1:1814 NE JENSEN BEACH BLVD
Practice Address - Street 2:
Practice Address - City:JENSEN BEACH
Practice Address - State:FL
Practice Address - Zip Code:34957-7234
Practice Address - Country:US
Practice Address - Phone:772-208-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-04
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL000174302171W00000X
FL000174301171W00000X
FL000174300171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000174302Medicaid
FL000174301Medicaid
FL000174300Medicaid