Healthcare Provider Details

I. General information

NPI: 1134872674
Provider Name (Legal Business Name): SHERLEY EDWINE VIXAMAR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2022
Last Update Date: 02/03/2022
Certification Date: 02/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

782 FOXRIDGE CENTER DR
ORANGE PARK FL
32065-5776
US

IV. Provider business mailing address

782 FOXRIDGE CENTER DR
ORANGE PARK FL
32065-5776
US

V. Phone/Fax

Practice location:
  • Phone: 904-637-1400
  • Fax: 904-800-4880
Mailing address:
  • Phone: 904-637-1400
  • Fax: 904-800-4880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-22-201189
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: