Healthcare Provider Details

I. General information

NPI: 1669304952
Provider Name (Legal Business Name): IVONNE LILIANA PERALTA APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8613 OLD KINGS RD S STE 602
JACKSONVILLE FL
32217-4863
US

IV. Provider business mailing address

121 CARIBBEAN PL
SAINT JOHNS FL
32259-2296
US

V. Phone/Fax

Practice location:
  • Phone: 904-493-3390
  • Fax: 904-493-3395
Mailing address:
  • Phone: 904-493-3390
  • Fax: 904-493-3395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11045757
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: