Healthcare Provider Details

I. General information

NPI: 1932232121
Provider Name (Legal Business Name): TERI ANN LAVENBARG ARNP-NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 02/19/2021
Certification Date: 02/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 HEALTH PARK BLVD
ST AUGUSTINE FL
32086-5776
US

IV. Provider business mailing address

130 HEALTH PARK BLVD
ST AUGUSTINE FL
32086-5776
US

V. Phone/Fax

Practice location:
  • Phone: 904-826-3469
  • Fax: 904-808-4608
Mailing address:
  • Phone: 904-826-3469
  • Fax: 904-808-4608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number14-55117-032
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11004784
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: