Healthcare Provider Details

I. General information

NPI: 1730060583
Provider Name (Legal Business Name): KASEY MARIE LAGOW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2025
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 SAINT ELIZABETH WAY STE 270
SAINT JOHNS FL
32259-1152
US

IV. Provider business mailing address

300 SAINT ELIZABETH WAY STE 270
SAINT JOHNS FL
32259-1152
US

V. Phone/Fax

Practice location:
  • Phone: 904-691-9130
  • Fax: 901-691-9159
Mailing address:
  • Phone: 904-691-9130
  • Fax: 901-691-9159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number11040595
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: