Healthcare Provider Details

I. General information

NPI: 1720868128
Provider Name (Legal Business Name): FIRST COAST WOUND CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2023
Last Update Date: 10/05/2023
Certification Date: 10/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9190 AUGUST CIR
SAINT AUGUSTINE FL
32080-8626
US

IV. Provider business mailing address

9190 AUGUST CIR
SAINT AUGUSTINE FL
32080-8626
US

V. Phone/Fax

Practice location:
  • Phone: 904-599-6131
  • Fax: 904-341-5529
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: KRISTI LORD
Title or Position: AUTHORIZED PERSON
Credential: FNP
Phone: 352-650-3446