Healthcare Provider Details

I. General information

NPI: 1992362404
Provider Name (Legal Business Name): IDA MARIE PALMER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2019
Last Update Date: 05/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6722 ARLINGTON EXPY # 570
JACKSONVILLE FL
32211-7234
US

IV. Provider business mailing address

6722 ARLINGTON EXPY # 570
JACKSONVILLE FL
32211-7234
US

V. Phone/Fax

Practice location:
  • Phone: 904-601-8426
  • Fax:
Mailing address:
  • Phone: 904-601-8426
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number103TH0100X
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: