Healthcare Provider Details

I. General information

NPI: 1740595271
Provider Name (Legal Business Name): PAM RILLSTONE, PHD, CNS, BC, CT, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2010
Last Update Date: 08/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6817 SOUTHPOINT PKWY STE 304
JACKSONVILLE FL
32216-6282
US

IV. Provider business mailing address

13801 VICTORIA LAKES DR
JACKSONVILLE FL
32226-4898
US

V. Phone/Fax

Practice location:
  • Phone: 904-296-3113
  • Fax: 904-296-3144
Mailing address:
  • Phone: 904-610-2761
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License NumberARNP 1247222
License Number StateFL

VIII. Authorized Official

Name: DR. PAM RILLSTONE
Title or Position: MANAGER
Credential: PHD, ARNP, CNS
Phone: 904-610-2761