Provider Demographics
NPI:1932822780
Name:RAYMOND, KOURTNEY MARIE
Entity Type:Individual
Prefix:
First Name:KOURTNEY
Middle Name:MARIE
Last Name:RAYMOND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2221 NW FEDERAL HWY APT 2441
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-9491
Mailing Address - Country:US
Mailing Address - Phone:570-687-5098
Mailing Address - Fax:
Practice Address - Street 1:1400 SE GOLDTREE DR STE 103
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7582
Practice Address - Country:US
Practice Address - Phone:772-335-8446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-26
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9116451363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1174521595Medicaid