Healthcare Provider Details

I. General information

NPI: 1871894972
Provider Name (Legal Business Name): GERISOURCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2010
Last Update Date: 11/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11812 CRUSSELLE DR
JACKSONVILLE FL
32223-0876
US

IV. Provider business mailing address

11812 CRUSSELLE DR
JACKSONVILLE FL
32223-0876
US

V. Phone/Fax

Practice location:
  • Phone: 904-252-5265
  • Fax:
Mailing address:
  • Phone: 904-252-5265
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number9260038
License Number StateFL

VIII. Authorized Official

Name: MRS. ANDREA H CLAYMAN
Title or Position: PRESIDENT
Credential: ARNP
Phone: 904-252-5265