Healthcare Provider Details

I. General information

NPI: 1083116107
Provider Name (Legal Business Name): KBN HEALTHCARE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2018
Last Update Date: 03/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9471 BAYMEADOWS RD STE 3
JACKSONVILLE FL
32256-7932
US

IV. Provider business mailing address

9471 BAYMEADOWS RD STE 3
JACKSONVILLE FL
32256-7932
US

V. Phone/Fax

Practice location:
  • Phone: 904-332-7431
  • Fax: 904-332-7408
Mailing address:
  • Phone: 904-332-7431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberARNP9239957
License Number StateFL

VIII. Authorized Official

Name: WENDY C LU
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 904-221-2535