Provider Demographics
NPI:1891064655
Name:WALSH, JACQUELYN MARIE (APRN)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:MARIE
Last Name:WALSH
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 1:3003 W TRILBY AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33611-4430
Mailing Address - Country:US
Mailing Address - Phone:813-777-9522
Mailing Address - Fax:
Practice Address - Street 1:625 6TH AVE S STE 310
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4664
Practice Address - Country:US
Practice Address - Phone:727-767-2243
Practice Address - Fax:727-767-4299
Is Sole Proprietor?:No
Enumeration Date:2011-12-23
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN214988363LF0000X
FLARNP9492462363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily