Healthcare Provider Details

I. General information

NPI: 1013553650
Provider Name (Legal Business Name): BRADLEY JAMES WINE RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2019
Last Update Date: 11/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 PRUDENTIAL DR
JACKSONVILLE FL
32207-8202
US

IV. Provider business mailing address

1010 N 102ND ST STE 300
OMAHA NE
68114-2122
US

V. Phone/Fax

Practice location:
  • Phone: 904-202-2000
  • Fax:
Mailing address:
  • Phone: 904-202-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License NumberRN9524431
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: