Healthcare Provider Details

I. General information

NPI: 1912556465
Provider Name (Legal Business Name): ALEX BLAKE HARDY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2019
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

807 CHILDRENS WAY
JACKSONVILLE FL
32207-8426
US

IV. Provider business mailing address

10140 CENTURION PKWY N
JACKSONVILLE FL
32256-0532
US

V. Phone/Fax

Practice location:
  • Phone: 904-697-3600
  • Fax: 904-687-3927
Mailing address:
  • Phone: 904-697-4199
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License Number11035568
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: