Healthcare Provider Details

I. General information

NPI: 1851676019
Provider Name (Legal Business Name): DARLENE NICOLE AMESBURY MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2011
Last Update Date: 10/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3574 US 1 S SUITE 113
ST AUGUSTINE FL
32086-6466
US

IV. Provider business mailing address

3574 US 1 S SUITE 113
ST AUGUSTINE FL
32086-6466
US

V. Phone/Fax

Practice location:
  • Phone: 904-797-3115
  • Fax: 904-797-2915
Mailing address:
  • Phone: 904-797-3115
  • Fax: 904-797-2915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH 9421
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: