Provider Demographics
NPI:1104524883
Name:KING, JASMINE SHAWNECE
Entity type:Individual
Prefix:
First Name:JASMINE
Middle Name:SHAWNECE
Last Name:KING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 564
Mailing Address - Street 2:
Mailing Address - City:BELLE GLADE
Mailing Address - State:FL
Mailing Address - Zip Code:33430-0564
Mailing Address - Country:US
Mailing Address - Phone:561-449-9661
Mailing Address - Fax:
Practice Address - Street 1:12901 BRUCE B DOWNS BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-4742
Practice Address - Country:US
Practice Address - Phone:561-449-9661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-21
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11026392367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered