Healthcare Provider Details

I. General information

NPI: 1447458211
Provider Name (Legal Business Name): MARIE GRANT BATES ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 HEALTH PARK BLVD
ST AUGUSTINE FL
32086-5784
US

IV. Provider business mailing address

4544 GOLF RIDGE DR
ELKTON FL
32033-4010
US

V. Phone/Fax

Practice location:
  • Phone: 904-819-4598
  • Fax: 907-819-5090
Mailing address:
  • Phone: 904-829-5031
  • Fax: 904-829-5031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP9174644
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: