Healthcare Provider Details

I. General information

NPI: 1558526145
Provider Name (Legal Business Name): GAYNELL L LIVINGSTON-HODGES MEDICAID PROVIDER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2008
Last Update Date: 07/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1320 BROAD ST SUITE # 202
JACKSONVILLE FL
32202-3902
US

IV. Provider business mailing address

1320 BROAD STN SUITE # 202
JACKSONVILLE FL
32202
US

V. Phone/Fax

Practice location:
  • Phone: 904-358-9487
  • Fax:
Mailing address:
  • Phone: 904-358-9487
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number6933335-96
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: