Healthcare Provider Details

I. General information

NPI: 1265830343
Provider Name (Legal Business Name): JEROME FOSAAEN RD, LD/N
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2014
Last Update Date: 12/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1605 SANTA MARIE CT
SAINT AUGUSTINE FL
32080-5478
US

IV. Provider business mailing address

1605 SANTA MARIE CT
SAINT AUGUSTINE FL
32080-5478
US

V. Phone/Fax

Practice location:
  • Phone: 904-417-7344
  • Fax:
Mailing address:
  • Phone: 904-417-7344
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberND4527
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: