Provider Demographics
NPI:1669069951
Name:LOVE, WAYNE CRAIG JR
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:CRAIG
Last Name:LOVE
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 45TH ST N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33713-5215
Mailing Address - Country:US
Mailing Address - Phone:727-515-8590
Mailing Address - Fax:
Practice Address - Street 1:625 6TH AVE S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4662
Practice Address - Country:US
Practice Address - Phone:727-498-8994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-21
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11006563363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics