Healthcare Provider Details

I. General information

NPI: 1396064077
Provider Name (Legal Business Name): KALONI HEPWORTH RD LD/N
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2010
Last Update Date: 02/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8825 PERIMETER PARK BLVD
JACKSONVILLE FL
32216-1108
US

IV. Provider business mailing address

8825 PERIMETER PARK BLVD
JACKSONVILLE FL
32216-1108
US

V. Phone/Fax

Practice location:
  • Phone: 904-645-5347
  • Fax:
Mailing address:
  • Phone: 904-645-5347
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberND 5722
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: