Healthcare Provider Details

I. General information

NPI: 1568132207
Provider Name (Legal Business Name): HAROLD VAN BARRY II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2021
Last Update Date: 10/27/2021
Certification Date: 10/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 NW COMMERCE DR
LAKE CITY FL
32055-4709
US

IV. Provider business mailing address

345 NW MANSFIELD DR
WHITE SPRINGS FL
32096-7608
US

V. Phone/Fax

Practice location:
  • Phone: 386-719-9000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number9423404
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN11015992
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: