Provider Demographics
NPI:1053993550
Name:FLORIDA BLUE STAR INC
Entity type:Organization
Organization Name:FLORIDA BLUE STAR INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADVANCED PRACTICE REGISTERED NURSE
Authorized Official - Prefix:
Authorized Official - First Name:YUDITH
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMON
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:305-803-4502
Mailing Address - Street 1:1525 SE 5TH CT
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33990-2019
Mailing Address - Country:US
Mailing Address - Phone:305-803-4502
Mailing Address - Fax:
Practice Address - Street 1:1325 SE 47TH ST STE I
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33904-9669
Practice Address - Country:US
Practice Address - Phone:239-205-2337
Practice Address - Fax:239-310-5287
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-23
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty