Healthcare Provider Details

I. General information

NPI: 1114619921
Provider Name (Legal Business Name): DIANA HOPE MANDERSON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2023
Last Update Date: 12/07/2025
Certification Date: 12/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 PRAIRIE RIDGE DR
ST AUGUSTINE FL
32092-1852
US

IV. Provider business mailing address

136 PRAIRIE RIDGE DR
ST AUGUSTINE FL
32092-1852
US

V. Phone/Fax

Practice location:
  • Phone: 904-404-6626
  • Fax:
Mailing address:
  • Phone: 904-404-6626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number11026420
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11026420
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: