Healthcare Provider Details

I. General information

NPI: 1245930502
Provider Name (Legal Business Name): EILEEN P FUENTES APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2023
Last Update Date: 11/02/2025
Certification Date: 11/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

807 CHILDRENS WAY
JACKSONVILLE FL
32207-8426
US

IV. Provider business mailing address

841 PRUDENTIAL DR STE 280
JACKSONVILLE FL
32207-8350
US

V. Phone/Fax

Practice location:
  • Phone: 904-697-3600
  • Fax: 904-687-3927
Mailing address:
  • Phone: 904-697-4100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberNP001351
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number11024537
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: