MEDICARE: MARY MARGARET BAZALDUA ARNP

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	363LF0000X	Family Nurse Practitioner	9234572	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	APRN 9234572	OTHER	FL	NURSE PRACTITIONER LICENS

General Provider Information

NPI Number	:	1124070446
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY MARGARET BAZALDUA ARNP

Provider Business Mailing Address
First Line	:	4049 MCGIRTS BLVD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32210-4340
Country	:	US
Telephone Number	:	812-480-3420
Fax Number	:

Provider Business Practice Location Address
First Line	:	6817 SOUTHPOINT PKWY
Second Line	:	SUITE 2304
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-6282
Country	:	US
Telephone Number	:	904-296-1874
Fax Number	:	904-296-1877

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

Provider Enumeration Date	:	05/16/2006
Last Update Date	:	07/08/2007

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