Healthcare Provider Details

I. General information

NPI: 1053071845
Provider Name (Legal Business Name): JOSEPH MICHAEL FITZGERALD FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2021
Last Update Date: 07/30/2024
Certification Date: 07/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 W TOWN PL STE 1
SAINT AUGUSTINE FL
32092-3102
US

IV. Provider business mailing address

319 W TOWN PL STE 1
SAINT AUGUSTINE FL
32092-3102
US

V. Phone/Fax

Practice location:
  • Phone: 904-940-1477
  • Fax:
Mailing address:
  • Phone: 904-955-1473
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0000031190
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95167477
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: