Healthcare Provider Details

I. General information

NPI: 1033776539
Provider Name (Legal Business Name): GREGG STEVEN HALVERSON APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2019
Last Update Date: 08/30/2023
Certification Date: 08/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1542 KINGSLEY AVE STE 136
ORANGE PARK FL
32073-4547
US

IV. Provider business mailing address

1542 KINGSLEY AVE STE 136
ORANGE PARK FL
32073-4547
US

V. Phone/Fax

Practice location:
  • Phone: 904-458-7780
  • Fax:
Mailing address:
  • Phone: 904-458-7780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2021033954
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11001570
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: