Provider Demographics
NPI:1144688680
Name:DORVAL, ANDRE (RN)
Entity type:Individual
Prefix:
First Name:ANDRE
Middle Name:
Last Name:DORVAL
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1258 SW ERMINE AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-5006
Mailing Address - Country:US
Mailing Address - Phone:772-207-7947
Mailing Address - Fax:772-333-2814
Practice Address - Street 1:11380 SW HILLCREST CIR
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34987-2704
Practice Address - Country:US
Practice Address - Phone:772-940-9219
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-28
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3747P1801X, 376K00000X
FL9279980163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012975500Medicaid