Basic Information
Provider Information | |||||||||
NPI: | 1619073921 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HORKINS | ||||||||
FirstName: | MARCIE | ||||||||
MiddleName: | ANNE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6830 S US HIGHWAY 1 | ||||||||
Address2: |   | ||||||||
City: | PORT ST LUCIE | ||||||||
State: | FL | ||||||||
PostalCode: | 349521410 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7728736700 | ||||||||
FaxNumber: | 7724655499 | ||||||||
Practice Location | |||||||||
Address1: | 2 COLUMBIA DR | ||||||||
Address2: | SUITE A 327 | ||||||||
City: | TAMPA | ||||||||
State: | FL | ||||||||
PostalCode: | 336063508 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8138444396 | ||||||||
FaxNumber: | 8138444972 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/15/2006 | ||||||||
LastUpdateDate: | 12/05/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | ARNP9268019 | FL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | 308913400 | 05 | FL |   | MEDICAID | 34488805 | 05 | AZ |   | MEDICAID | G4437 | 01 | FL | BCBS | OTHER |