Provider Demographics
NPI:1043826688
Name:PRINCE, GREGORY WADE (ARNP, FNP-C)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:WADE
Last Name:PRINCE
Suffix:
Gender:M
Credentials:ARNP, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1790 WATERSIDE OAKS DR
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-9206
Mailing Address - Country:US
Mailing Address - Phone:256-612-0173
Mailing Address - Fax:
Practice Address - Street 1:701 W PLYMOUTH AVE
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-3236
Practice Address - Country:US
Practice Address - Phone:386-943-3160
Practice Address - Fax:386-943-3169
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-18
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP11009727163WG0000X
FLAPRN11009727363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WG0000XNursing Service ProvidersRegistered NurseGeneral PracticeGroup - Multi-Specialty