Healthcare Provider Details

I. General information

NPI: 1891381133
Provider Name (Legal Business Name): DIANA BUDNIK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2020
Last Update Date: 03/17/2021
Certification Date: 03/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3625 UNIVERSITY BLVD S
JACKSONVILLE FL
32216-4207
US

IV. Provider business mailing address

601 1ST ST S APT 2H
JACKSONVILLE BEACH FL
32250-6657
US

V. Phone/Fax

Practice location:
  • Phone: 904-702-6111
  • Fax:
Mailing address:
  • Phone: 904-477-7076
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number9452553
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number11012166
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: