Healthcare Provider Details

I. General information

NPI: 1689645020
Provider Name (Legal Business Name): BRAD A BRISCOE APRN, ACNP-BC, CNS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2006
Last Update Date: 05/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3122 NEW BERLIN RD
JACKSONVILLE FL
32226-1828
US

IV. Provider business mailing address

653 W 8TH ST P.O. BOX 44008
JACKSONVILLE FL
32209-6511
US

V. Phone/Fax

Practice location:
  • Phone: 904-633-0340
  • Fax:
Mailing address:
  • Phone: 904-244-3500
  • Fax: 904-244-3425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number1067675
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number2590432
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: