Healthcare Provider Details

I. General information

NPI: 1164751707
Provider Name (Legal Business Name): DR. MARY'S PLACE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2009
Last Update Date: 04/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4051 ATLANTIC BLVD
JACKSONVILLE FL
32207-2036
US

IV. Provider business mailing address

4051 ATLANTIC BLVD
JACKSONVILLE FL
32207-2036
US

V. Phone/Fax

Practice location:
  • Phone: 904-393-4700
  • Fax: 904-493-9700
Mailing address:
  • Phone: 904-393-4700
  • Fax: 904-493-9700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberARNP9271693
License Number StateFL

VIII. Authorized Official

Name: MS. CARA MARIE D'AMICO
Title or Position: PEDIATRIC ARNP
Credential: C-PNP, ARNP
Phone: 904-642-6100