Healthcare Provider Details

I. General information

NPI: 1487291837
Provider Name (Legal Business Name): LEE WILLINGHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2019
Last Update Date: 06/02/2022
Certification Date: 06/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3625 UNIVERSITY BLVD S
JACKSONVILLE FL
32216-4207
US

IV. Provider business mailing address

7651 GATE PKWY APT 2208
JACKSONVILLE FL
32256-4822
US

V. Phone/Fax

Practice location:
  • Phone: 904-702-6111
  • Fax:
Mailing address:
  • Phone: 770-315-5101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9438255
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number246202
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: