Healthcare Provider Details

I. General information

NPI: 1861228272
Provider Name (Legal Business Name): PRISCILA SIMON JOSE FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2024
Last Update Date: 09/11/2024
Certification Date: 08/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 NW COMMERCE DR
LAKE CITY FL
32055-4709
US

IV. Provider business mailing address

7480 S STATE ROAD 121
MACCLENNY FL
32063-5450
US

V. Phone/Fax

Practice location:
  • Phone: 386-719-9000
  • Fax:
Mailing address:
  • Phone: 386-249-2131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11035219
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: