Healthcare Provider Details

I. General information

NPI: 1477208288
Provider Name (Legal Business Name): TONJAMEKA R SOUTHERN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2022
Last Update Date: 02/21/2022
Certification Date: 01/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 N MARKET ST
JACKSONVILLE FL
32202
US

IV. Provider business mailing address

4674 EMPIRE AVE
JACKSONVILLE FL
32207-2191
US

V. Phone/Fax

Practice location:
  • Phone: 317-514-0857
  • Fax:
Mailing address:
  • Phone: 317-514-0857
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9521589
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code173C00000X
TaxonomyReflexologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberRN9521589
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code2083C0008X
TaxonomyClinical Informatics Physician
License NumberRN9521589
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code405300000X
TaxonomyPrevention Professional
License NumberRN9521589
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: