MEDICARE: RAENA PATTERSON

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	390200000X	Student in an Organized Health Care Education/Training Program		FL
2	122300000X	Dentist	DN30784	FL

General Provider Information

NPI Number	:	1174414619
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RAENA PATTERSON

Provider Business Mailing Address
First Line	:	1485 FOURAKER RD APT 3410
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32221-7601
Country	:	US
Telephone Number	:	904-635-6521
Fax Number	:

Provider Business Practice Location Address
First Line	:	8324 MERCHANTS WAY UNIT 9
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32222-2946
Country	:	US
Telephone Number	:	904-420-6331
Fax Number	:

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

Provider Enumeration Date	:	07/12/2025
Last Update Date	:	07/15/2025

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Directions to “ RAENA PATTERSON ” Practice Location

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