Healthcare Provider Details

I. General information

NPI: 1609294552
Provider Name (Legal Business Name): JOANNE PEREZ-VERGARA RDN. LD/N
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2014
Last Update Date: 10/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2799 TURTLE SHORES DR
FERNANDINA BEACH FL
32034-6645
US

IV. Provider business mailing address

2799 TURTLE SHORES DR
FERNANDINA BEACH FL
32034-6645
US

V. Phone/Fax

Practice location:
  • Phone: 864-436-7324
  • Fax:
Mailing address:
  • Phone: 912-443-4200
  • Fax: 912-644-5260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLDN8288
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD004223
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: