Healthcare Provider Details

I. General information

NPI: 1437754975
Provider Name (Legal Business Name): LOREN ELIZABETH PERES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2020
Last Update Date: 02/01/2021
Certification Date: 01/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 KINGSLEY AVE
ORANGE PARK FL
32073-5156
US

IV. Provider business mailing address

235 COCONUT PALM PKWY
PONTE VEDRA FL
32081-6076
US

V. Phone/Fax

Practice location:
  • Phone: 904-639-8500
  • Fax:
Mailing address:
  • Phone: 904-612-6466
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN11011082
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: