Healthcare Provider Details

I. General information

NPI: 1659168516
Provider Name (Legal Business Name): DREAM PRIMARY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2025
Last Update Date: 04/30/2025
Certification Date: 04/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2255 DUNN AVE STE 503
JACKSONVILLE FL
32218-4742
US

IV. Provider business mailing address

2255 DUNN AVE STE 503
JACKSONVILLE FL
32218-4742
US

V. Phone/Fax

Practice location:
  • Phone: 904-521-7564
  • Fax:
Mailing address:
  • Phone: 904-521-7564
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: TATIANNA MILES
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 904-868-8923