Healthcare Provider Details

I. General information

NPI: 1376191700
Provider Name (Legal Business Name): CHERYL MCGRUDER APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2019
Last Update Date: 08/04/2022
Certification Date: 08/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3059 EDGEWOOD AVE W
JACKSONVILLE FL
32209-2207
US

IV. Provider business mailing address

3059 EDGEWOOD AVE W
JACKSONVILLE FL
32209-2207
US

V. Phone/Fax

Practice location:
  • Phone: 904-647-3180
  • Fax: 904-425-9030
Mailing address:
  • Phone: 904-647-3180
  • Fax: 904-425-9030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN11002024
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: