Provider Demographics
NPI:1588259196
Name:WOOLVERTON, JONATHAN (APRN)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:WOOLVERTON
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 LOOKOUT DR
Mailing Address - Street 2:
Mailing Address - City:APOLLO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33572-2664
Mailing Address - Country:US
Mailing Address - Phone:813-409-4587
Mailing Address - Fax:
Practice Address - Street 1:227 LOOKOUT DR
Practice Address - Street 2:
Practice Address - City:APOLLO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33572-2664
Practice Address - Country:US
Practice Address - Phone:813-502-9070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-05
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9505164163W00000X
FLAPRN11012483363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse