Healthcare Provider Details

I. General information

NPI: 1780055152
Provider Name (Legal Business Name): KASSANDRA LEANN GNANN ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2015
Last Update Date: 06/10/2021
Certification Date: 06/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1563 KINGSLEY AVENUE SUITE 106
ORANGE PARK FL
32073
US

IV. Provider business mailing address

2 SHIRCLIFF WAY SUITE 700 DEPAUL BLDG
JACKSONVILLE FL
32204
US

V. Phone/Fax

Practice location:
  • Phone: 904-389-5333
  • Fax: 904-389-5332
Mailing address:
  • Phone: 904-389-5333
  • Fax: 904-389-5332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP 9337434
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN9337434
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: