Provider Demographics
NPI:1093305062
Name:BURGOS, JESSICA (RN)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BURGOS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:466 SW PORT ST LUCIE BLVD STE 114
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-2091
Mailing Address - Country:US
Mailing Address - Phone:772-837-0500
Mailing Address - Fax:772-264-7903
Practice Address - Street 1:466 SW PORT ST LUCIE BLVD STE 114
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-2091
Practice Address - Country:US
Practice Address - Phone:772-837-0500
Practice Address - Fax:772-264-7903
Is Sole Proprietor?:No
Enumeration Date:2021-01-22
Last Update Date:2024-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041403333163W00000X
FL736163WH0200X
FL777163WI0500X
FLRN9562775163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WI0500XNursing Service ProvidersRegistered NurseInfusion Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6029027OtherHEALTH CARE CLINIC ESTABLISHMENT
FL10D2300231OtherCLIA WAIVER