Provider Demographics
NPI:1194344820
Name:TIPPETT, JACQUELINE DIANE (APRN, AGACNP-BC)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:DIANE
Last Name:TIPPETT
Suffix:
Gender:F
Credentials:APRN, AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 SW 2ND AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:DANIA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33004-3922
Mailing Address - Country:US
Mailing Address - Phone:937-475-0952
Mailing Address - Fax:
Practice Address - Street 1:610 SW 2ND AVE APT 1
Practice Address - Street 2:
Practice Address - City:DANIA BEACH
Practice Address - State:FL
Practice Address - Zip Code:33004-3922
Practice Address - Country:US
Practice Address - Phone:937-475-0952
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-13
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11006764363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care