Provider Demographics
NPI: | 1669835112 |
---|---|
Name: | ARRIETA, REYNALDO E (APRN) |
Entity Type: | Individual |
Prefix: | |
First Name: | REYNALDO |
Middle Name: | E |
Last Name: | ARRIETA |
Suffix: | |
Gender: | M |
Credentials: | APRN |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 1400 NW 107TH AVE STE 500 |
Mailing Address - Street 2: | |
Mailing Address - City: | SWEETWATER |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 33172-2746 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 6245 66TH ST N |
Practice Address - Street 2: | |
Practice Address - City: | PINELLAS PARK |
Practice Address - State: | FL |
Practice Address - Zip Code: | 33781-5025 |
Practice Address - Country: | US |
Practice Address - Phone: | 727-873-3891 |
Practice Address - Fax: | |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2016-04-01 |
Last Update Date: | 2022-01-18 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
171M00000X | ||
FL | 9500673 | 163W00000X |
FL | APRN11016387 | 363LF0000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No | 171M00000X | Other Service Providers | Case Manager/Care Coordinator | |
No | 163W00000X | Nursing Service Providers | Registered Nurse |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
FL | 1971 | Medicaid |