Provider Demographics
NPI:1831667062
Name:BOGLE, JACQUELINE (APRN)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:BOGLE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1334 OAKCREST CT
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33837-1707
Mailing Address - Country:US
Mailing Address - Phone:863-409-6818
Mailing Address - Fax:
Practice Address - Street 1:1334 OAKCREST CT
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33837-1707
Practice Address - Country:US
Practice Address - Phone:863-409-6818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-06
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9303392207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL9303392OtherFLORIDA BOARD OF NURSING