Healthcare Provider Details

I. General information

NPI: 1780490649
Provider Name (Legal Business Name): ANNA MOON FARRELL MS., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2024
Last Update Date: 02/11/2026
Certification Date: 02/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 MARINER HEALTH WAY STE 213
ST AUGUSTINE FL
32086-3251
US

IV. Provider business mailing address

5B SYLVAN DR
SAINT AUGUSTINE FL
32084-2121
US

V. Phone/Fax

Practice location:
  • Phone: 904-217-4259
  • Fax: 904-217-4251
Mailing address:
  • Phone: 904-610-4025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA15779
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: