Healthcare Provider Details

I. General information

NPI: 1619411279
Provider Name (Legal Business Name): BRECK BAKER PMHNP -BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2016
Last Update Date: 09/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 SAN SEBASTIAN VW STE 2102
ST AUGUSTINE FL
32084-8695
US

IV. Provider business mailing address

200 SAN SEBASTIAN VW STE 2102
ST AUGUSTINE FL
32084-8695
US

V. Phone/Fax

Practice location:
  • Phone: 800-539-4228
  • Fax: 904-209-6288
Mailing address:
  • Phone: 800-539-4228
  • Fax: 904-209-6288

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN 256580
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN11001264
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: