| Entity Name: | ST.PETE NURSE PRACTITIONER, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Company |
| Status: | Active |
| Date Filed: | 06 Apr 2022 (3 years ago) |
| Last Event: | AMENDMENT |
| Event Date Filed: | 02 May 2022 (3 years ago) |
| Document Number: | L22000166057 |
| FEI/EIN Number | 88-1948325 |
| Address: | 33 4TH STREET NORTH, ST.PETERSBURG, FL 33701 |
| Mail Address: | 4670 CHANCELLOR ST NE, ST.PETERSBURG, FL 33703 |
| ZIP code: | 33701 |
| County: | Pinellas |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1720724297 | 2022-05-09 | 2022-05-09 | 4670 CHANCELLOR ST NE, SAINT PETERSBURG, FL, 337034345, US | 33 4TH ST N STE 202, SAINT PETERSBURG, FL, 337013806, US | |||||||||||||||||||
|
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| Phone | +1 727-686-8284 |
Authorized person
| Name | JESSICA CARABALLO |
| Role | PRESIDENT |
| Phone | 7276868284 |
Taxonomy
| Taxonomy Code | 261QP2300X - Primary Care Clinic/Center |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 1437649100 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| CARABALLO, JESSICA A | Agent | 4670 CHANCELLOR ST NE, ST.PETE, FL 33703 |
| Name | Role | Address |
|---|---|---|
| CARABALLO, JESSICA | Chief Executive Officer | 4670 CHANCELLOR ST. NE, ST. PETERSBURG, FL 33703 |
| Name | Role | Address |
|---|---|---|
| CARABALLO, JESSICA | President | 4670 CHANCELLOR ST. NE, ST. PETERSBURG, FL 33703 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2022-05-17 | 33 4TH STREET NORTH, ST.PETERSBURG, FL 33701 | No data |
| AMENDMENT | 2022-05-02 | No data | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-04-11 |
| ANNUAL REPORT | 2023-03-06 |
| Amendment | 2022-05-02 |
| Florida Limited Liability | 2022-04-06 |
Date of last update: 12 Jan 2025
Sources: Florida Department of State
