Healthcare Provider Details

I. General information

NPI: 1285485698
Provider Name (Legal Business Name): YOUR WAY PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2024
Last Update Date: 02/12/2025
Certification Date: 02/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 TOWN PLAZA AVE STE 330
PONTE VEDRA FL
32081-5175
US

IV. Provider business mailing address

360 TOWN PLAZA AVE STE 330
PONTE VEDRA FL
32081-5175
US

V. Phone/Fax

Practice location:
  • Phone: 904-419-9086
  • Fax: 864-448-1482
Mailing address:
  • Phone: 904-419-9086
  • Fax: 864-448-1482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MRS. CHRISTINA M RALKO
Title or Position: NURSE PRACTITIONER
Credential: APRN
Phone: 313-629-1552