Healthcare Provider Details

I. General information

NPI: 1174434955
Provider Name (Legal Business Name): CORINNA ENID TEMPLE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2377 MARKET DR
FLEMING ISLAND FL
32003-4326
US

IV. Provider business mailing address

2377 MARKET DR
FLEMING ISLAND FL
32003-4326
US

V. Phone/Fax

Practice location:
  • Phone: 904-579-4779
  • Fax: 904-579-4779
Mailing address:
  • Phone: 904-579-4779
  • Fax: 904-579-4779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: