Healthcare Provider Details

I. General information

NPI: 1891098737
Provider Name (Legal Business Name): SHIRLEY ANN ARLINE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHIRLEY JONES DUPREE

II. Dates (important events)

Enumeration Date: 12/15/2010
Last Update Date: 12/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2331 LANE AVE S
JACKSONVILLE FL
32210-3703
US

IV. Provider business mailing address

2331 LANE AVE S
JACKSONVILLE FL
32210-3703
US

V. Phone/Fax

Practice location:
  • Phone: 904-434-5864
  • Fax: 904-683-2821
Mailing address:
  • Phone: 904-434-5864
  • Fax: 904-683-2821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number683297196
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: