Basic Information
| Provider Information | |||||||||
| NPI: | 1841821808 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHORE | ||||||||
| FirstName: | OLIVIA | ||||||||
| MiddleName: | WHITE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WHITE | ||||||||
| OtherFirstName: | OLIVIA | ||||||||
| OtherMiddleName: | SARAH | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4205 BELFORT RD STE 4015 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322163623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044506014 | ||||||||
| FaxNumber: | 9044506401 | ||||||||
| Practice Location | |||||||||
| Address1: | 1549 AIRPORT BLVD STE 200B | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325048634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504164600 | ||||||||
| FaxNumber: | 8504162533 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2020 | ||||||||
| LastUpdateDate: | 04/23/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | APRN11005661 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.