Healthcare Provider Details

I. General information

NPI: 1417124892
Provider Name (Legal Business Name): MRS. KATRINA LEFAYE JAMES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2008
Last Update Date: 05/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3504 NORTH DAVIS STREET
JACKSONVILLE FL
32209-4456
US

IV. Provider business mailing address

3504 NORTH DAVIS STREET
JACKSONVILLE FL
32209-4456
US

V. Phone/Fax

Practice location:
  • Phone: 904-632-2019
  • Fax: 904-632-2019
Mailing address:
  • Phone: 904-632-2019
  • Fax: 904-632-2019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number69042596
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number08IV028
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: