Provider Demographics
NPI:1639951528
Name:PORTILLO, ROSA MARIA (FNP-C)
Entity Type:Individual
Prefix:
First Name:ROSA
Middle Name:MARIA
Last Name:PORTILLO
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:368 MERLIN CT
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32539-6753
Mailing Address - Country:US
Mailing Address - Phone:469-583-0709
Mailing Address - Fax:
Practice Address - Street 1:501 N SPRING ST
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-3314
Practice Address - Country:US
Practice Address - Phone:850-460-7090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-16
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11029002363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily