Healthcare Provider Details

I. General information

NPI: 1194789958
Provider Name (Legal Business Name): PENNIC, WOOTEN& ASSOCIATES FAMILY MEDICAL CARE PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1760 EDGEWOOD AVE W B
JACKSONVILLE FL
32208-7209
US

IV. Provider business mailing address

1760 EDGEWOOD AVE W B
JACKSONVILLE FL
32208-7209
US

V. Phone/Fax

Practice location:
  • Phone: 904-358-8480
  • Fax: 904-358-8460
Mailing address:
  • Phone: 904-358-8480
  • Fax: 904-358-8460

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateFL

VIII. Authorized Official

Name: SONYA LUCAS
Title or Position: OFFICE MANANGER
Credential:
Phone: 904-358-8480