Healthcare Provider Details

I. General information

NPI: 1609303627
Provider Name (Legal Business Name): JOANNA BALD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2017
Last Update Date: 05/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10475 CENTURION PKWY N STE 304
JACKSONVILLE FL
32256-5004
US

IV. Provider business mailing address

3901 UNIVERSITY BLVD S
JACKSONVILLE FL
32216-4312
US

V. Phone/Fax

Practice location:
  • Phone: 904-854-2050
  • Fax:
Mailing address:
  • Phone: 904-345-7336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA27110
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: