Provider Demographics
NPI:1396134904
Name:GLOVER, PORTIA ANTOINETTE (ARNP)
Entity type:Individual
Prefix:DR
First Name:PORTIA
Middle Name:ANTOINETTE
Last Name:GLOVER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5851 TIMUQUANA RD STE 104
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-7890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5851 TIMUQUANA RD STE 104
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-7890
Practice Address - Country:US
Practice Address - Phone:904-416-0601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-20
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9320168363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015070500Medicaid