Healthcare Provider Details

I. General information

NPI: 1700400496
Provider Name (Legal Business Name): MARISA MICHELLE LAUGHREY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2020
Last Update Date: 11/20/2025
Certification Date: 11/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4125 RACE TRACK RD UNIT 104
ST JOHNS FL
32259-2389
US

IV. Provider business mailing address

4125 RACE TRACK RD UNIT 104
ST JOHNS FL
32259-2389
US

V. Phone/Fax

Practice location:
  • Phone: 904-222-6364
  • Fax: 904-342-0442
Mailing address:
  • Phone: 904-222-6364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME163085
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: