Healthcare Provider Details

I. General information

NPI: 1164044608
Provider Name (Legal Business Name): DENISE POLLOCK FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2020
Last Update Date: 08/20/2021
Certification Date: 08/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1029 BUTTERCUP DR
ST JOHNS FL
32259-4511
US

IV. Provider business mailing address

1029 BUTTERCUP DR
ST JOHNS FL
32259-4511
US

V. Phone/Fax

Practice location:
  • Phone: 540-793-1563
  • Fax:
Mailing address:
  • Phone: 540-793-1563
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024179226
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11011185
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: