MEDICARE: ROBERT CHARLES PONTE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	APRN11039913	FL

General Provider Information

NPI Number	:	1093692055
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERT CHARLES PONTE

Provider Business Mailing Address
First Line	:	1540 WHITEHALL LN
Second Line	:
City	:	FLEMING ISLAND
State	:	FL
Zip	:	32003-7296
Country	:	US
Telephone Number	:	904-673-8543
Fax Number	:

Provider Business Practice Location Address
First Line	:	462 KINGSLEY AVE STE 103
Second Line	:
City	:	ORANGE PARK
State	:	FL
Zip	:	32073-4849
Country	:	US
Telephone Number	:	904-673-8543
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/20/2025
Last Update Date	:	06/04/2026

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