Provider Demographics
NPI:1639461023
Name:WHITAKER, NYDIA M (ARNP)
Entity type:Individual
Prefix:
First Name:NYDIA
Middle Name:M
Last Name:WHITAKER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:770 SW AVENS ST
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-8757
Mailing Address - Country:US
Mailing Address - Phone:772-380-3144
Mailing Address - Fax:877-733-7082
Practice Address - Street 1:800 VIRGINIA AVE STE 59B
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34982-5892
Practice Address - Country:US
Practice Address - Phone:772-577-6323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-04
Last Update Date:2024-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL000174302171W00000X
FL000174301171W00000X
FL000174300171W00000X
FLAPRN11029135363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000174301Medicaid
FL000174302Medicaid
FL000174300Medicaid