Provider Demographics
NPI:1639479900
Name:BLOODWORTH, JENNIFER MARIE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:BLOODWORTH
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:MARIE
Other - Last Name:FAZIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1137
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32902-1137
Mailing Address - Country:US
Mailing Address - Phone:321-952-9696
Mailing Address - Fax:321-952-7937
Practice Address - Street 1:5270 BABCOCK ST NE
Practice Address - Street 2:SUITE 1
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-8630
Practice Address - Country:US
Practice Address - Phone:321-722-5959
Practice Address - Fax:321-722-5960
Is Sole Proprietor?:No
Enumeration Date:2010-11-02
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9310812363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003241600Medicaid