Healthcare Provider Details

I. General information

NPI: 1053832220
Provider Name (Legal Business Name): FAYE NELSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2017
Last Update Date: 07/21/2022
Certification Date: 05/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2125 HYDE PARK RD APT 2
JACKSONVILLE FL
32210-3857
US

IV. Provider business mailing address

2125 HYDE PARK RD APT 21
JACKSONVILLE FL
32210-3876
US

V. Phone/Fax

Practice location:
  • Phone: 904-610-7479
  • Fax:
Mailing address:
  • Phone: 904-400-2232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: