Provider Demographics
NPI:1043992514
Name:CLEMENTS, TINYA C (APRN)
Entity type:Individual
Prefix:
First Name:TINYA
Middle Name:C
Last Name:CLEMENTS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2190 SE GENOA ST
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-7333
Mailing Address - Country:US
Mailing Address - Phone:772-380-7897
Mailing Address - Fax:
Practice Address - Street 1:1070 SW GATLIN BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953
Practice Address - Country:US
Practice Address - Phone:772-408-9434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-03
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11027893363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily