Healthcare Provider Details

I. General information

NPI: 1821899196
Provider Name (Legal Business Name): WELL POINT HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2025
Last Update Date: 04/01/2025
Certification Date: 04/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3661 HAWKS LANDING CIR
PACE FL
32571-9654
US

IV. Provider business mailing address

3661 HAWKS LANDING CIR
PACE FL
32571-9654
US

V. Phone/Fax

Practice location:
  • Phone: 904-655-9223
  • Fax:
Mailing address:
  • Phone: 904-655-9223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name: JOHN-MARK MILLER MOORE
Title or Position: PRESIDENT
Credential: BCBA
Phone: 904-655-9223