Provider Demographics
NPI:1538162185
Name:PONTELLO, RUBY (ARNP)
Entity type:Individual
Prefix:
First Name:RUBY
Middle Name:
Last Name:PONTELLO
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:PO BOX 555
Mailing Address - Street 2:
Mailing Address - City:DARIEN
Mailing Address - State:GA
Mailing Address - Zip Code:31305-0555
Mailing Address - Country:US
Mailing Address - Phone:850-508-5930
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 555
Practice Address - Street 2:
Practice Address - City:DARIEN
Practice Address - State:GA
Practice Address - Zip Code:31305-0555
Practice Address - Country:US
Practice Address - Phone:850-508-5930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2025-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9184570363L00000X
GARN081670363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL304495500Medicaid
FL304495500Medicaid