Provider Demographics
NPI:1548044837
Name:TENGCO, JUDITH CHARLES (APRN)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:CHARLES
Last Name:TENGCO
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:JUDITH
Other - Middle Name:
Other - Last Name:TENGCO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:2492 SE LAKEWOOD ST
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-7339
Mailing Address - Country:US
Mailing Address - Phone:772-812-7264
Mailing Address - Fax:
Practice Address - Street 1:2215 NEBRASKA AVE STE 2-E
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-4866
Practice Address - Country:US
Practice Address - Phone:772-461-6812
Practice Address - Fax:772-461-6816
Is Sole Proprietor?:No
Enumeration Date:2023-08-21
Last Update Date:2024-02-10
Deactivation Date:2023-10-14
Deactivation Code:
Reactivation Date:2023-11-08
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11029168363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily