Healthcare Provider Details

I. General information

NPI: 1093692055
Provider Name (Legal Business Name): ROBERT CHARLES PONTE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2025
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

462 KINGSLEY AVE STE 103
ORANGE PARK FL
32073-4849
US

IV. Provider business mailing address

1540 WHITEHALL LN
FLEMING ISLAND FL
32003-7296
US

V. Phone/Fax

Practice location:
  • Phone: 904-673-8543
  • Fax:
Mailing address:
  • Phone: 904-673-8543
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN11039913
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: