Healthcare Provider Details

I. General information

NPI: 1316641921
Provider Name (Legal Business Name): LEILANI MARIE DULLAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2023
Last Update Date: 03/28/2023
Certification Date: 03/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1904 FARRAGUT PL
JACKSONVILLE FL
32207-3420
US

IV. Provider business mailing address

607 MORNING MIST WAY
ORANGE PARK FL
32073-7674
US

V. Phone/Fax

Practice location:
  • Phone: 904-503-0131
  • Fax:
Mailing address:
  • Phone: 904-697-6664
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-23-264635
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: