Healthcare Provider Details

I. General information

NPI: 1013485051
Provider Name (Legal Business Name): JENNIFER CARLY BLAIRE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2018
Last Update Date: 11/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6500 W NEWBERRY RD
GAINESVILLE FL
32605-4392
US

IV. Provider business mailing address

7222 NW 43RD LN
GAINESVILLE FL
32606-3908
US

V. Phone/Fax

Practice location:
  • Phone: 352-333-4611
  • Fax:
Mailing address:
  • Phone: 352-359-1062
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN9262861
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: