Provider Demographics
NPI:1669188504
Name:PINKSTON, NYDALE ISAIAH (FNP)
Entity type:Individual
Prefix:
First Name:NYDALE
Middle Name:ISAIAH
Last Name:PINKSTON
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3525 W CAMPBELL RD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33810-4431
Mailing Address - Country:US
Mailing Address - Phone:863-419-5470
Mailing Address - Fax:
Practice Address - Street 1:3525 W CAMPBELL RD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33810-4431
Practice Address - Country:US
Practice Address - Phone:863-419-5470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-24
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLF01231101363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily