Healthcare Provider Details

I. General information

NPI: 1164237020
Provider Name (Legal Business Name): MARY ELIZABETH TRASK MSN, NNP, BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2025
Last Update Date: 02/10/2025
Certification Date: 02/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 W 8TH ST
JACKSONVILLE FL
32209-6511
US

IV. Provider business mailing address

1508 AVALON CT
JACKSONVILLE FL
32259-4517
US

V. Phone/Fax

Practice location:
  • Phone: 904-244-3508
  • Fax:
Mailing address:
  • Phone: 904-424-1677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN91686386
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: