Healthcare Provider Details

I. General information

NPI: 1720407315
Provider Name (Legal Business Name): JOHNATHAN NOEL WEBER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2014
Last Update Date: 04/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

439 SW MICHIGAN ST. MERIDIAN HEALTH
LAKE CITY FL
32025
US

IV. Provider business mailing address

18850 B F FINLEY CIR
GLEN ST MARY FL
32040-5674
US

V. Phone/Fax

Practice location:
  • Phone: 386-487-0800
  • Fax:
Mailing address:
  • Phone: 904-755-2740
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License NumberCNA 296175
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: