Healthcare Provider Details

I. General information

NPI: 1548769490
Provider Name (Legal Business Name): CINNAMON LEE CARLSON PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CINNAMON LEE BRINKMAN NONE

II. Dates (important events)

Enumeration Date: 02/06/2018
Last Update Date: 05/13/2021
Certification Date: 05/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 SAN SEBASTIAN VW
ST AUGUSTINE FL
32084-8695
US

IV. Provider business mailing address

2621 E JEFFERSON ST
WARSAW IN
46580-3880
US

V. Phone/Fax

Practice location:
  • Phone: 904-209-6200
  • Fax:
Mailing address:
  • Phone: 574-267-7169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number9196197
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: