Healthcare Provider Details

I. General information

NPI: 1952818809
Provider Name (Legal Business Name): KATHLEEN A GANNON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/01/2018
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5191 FIRST COAST TECH PKWY # 3
JACKSONVILLE FL
32224-0609
US

IV. Provider business mailing address

11945 SAN JOSE BLVD STE 300
JACKSONVILLE FL
32223-1627
US

V. Phone/Fax

Practice location:
  • Phone: 904-675-4000
  • Fax: 904-675-4007
Mailing address:
  • Phone: 904-376-1726
  • Fax: 904-376-4893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11035733
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN11035733
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71007340A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: