Healthcare Provider Details

I. General information

NPI: 1376854497
Provider Name (Legal Business Name): DORETTE MARIE NYSEWANDER EDD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2010
Last Update Date: 10/23/2023
Certification Date: 09/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 WINDMEADOWS BLVD. #97
GAINESVILLE FL
32608
US

IV. Provider business mailing address

1650 MARGARET ST STE 302 PMB 342
JACKSONVILLE FL
32204-3868
US

V. Phone/Fax

Practice location:
  • Phone: 904-859-1425
  • Fax:
Mailing address:
  • Phone: 904-859-1425
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number StateFL
# 8
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: