Healthcare Provider Details

I. General information

NPI: 1821314683
Provider Name (Legal Business Name): CATHLEEN HELENA SOUTHALL ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2010
Last Update Date: 04/22/2021
Certification Date: 04/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2606 PARK ST
JACKSONVILLE FL
32204-4520
US

IV. Provider business mailing address

3300 S FISKE BLVD
ROCKLEDGE FL
32955-4306
US

V. Phone/Fax

Practice location:
  • Phone: 904-388-4646
  • Fax: 904-388-9017
Mailing address:
  • Phone: 904-388-4646
  • Fax: 904-388-9017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberARNP9232015
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: