Provider Demographics
NPI:1063555027
Name:HUMPHREYS, JAN S (ARNP-C)
Entity type:Individual
Prefix:
First Name:JAN
Middle Name:S
Last Name:HUMPHREYS
Suffix:
Gender:F
Credentials:ARNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 PASADENA AVE S
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33707-2128
Mailing Address - Country:US
Mailing Address - Phone:727-345-7100
Mailing Address - Fax:727-345-7100
Practice Address - Street 1:630 PASADENA AVE S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33707-2128
Practice Address - Country:US
Practice Address - Phone:727-345-7100
Practice Address - Fax:727-345-7100
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 1163832363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
U37872Medicare ID - Type Unspecified
Q28383Medicare UPIN