Provider Demographics
NPI:1912666504
Name:PRIDEMORE, JOCELYN (RN, IBCLC)
Entity Type:Individual
Prefix:
First Name:JOCELYN
Middle Name:
Last Name:PRIDEMORE
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 TIFTON ST S
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33711-3647
Mailing Address - Country:US
Mailing Address - Phone:727-214-4712
Mailing Address - Fax:
Practice Address - Street 1:5817 15TH AVE S
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:FL
Practice Address - Zip Code:33707-3336
Practice Address - Country:US
Practice Address - Phone:727-214-4712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-11
Last Update Date:2021-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN2834682163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant