Provider Demographics
NPI:1033661624
Name:DONALDSON, REGINA R
Entity type:Individual
Prefix:MRS
First Name:REGINA
Middle Name:R
Last Name:DONALDSON
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 1:800 VIRGINIA AVE STE 598
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34982-5892
Mailing Address - Country:US
Mailing Address - Phone:772-332-3339
Mailing Address - Fax:772-323-0142
Practice Address - Street 1:2695 NW HATCHES HARBOR RD APT 101
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983-4127
Practice Address - Country:US
Practice Address - Phone:772-332-3339
Practice Address - Fax:772-323-0055
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-28
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL172V00000X, 261QD1600X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No172V00000XOther Service ProvidersCommunity Health Worker
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019040200Medicaid
FL109053700Medicaid