Healthcare Provider Details

I. General information

NPI: 1265296263
Provider Name (Legal Business Name): RHIANNA FAGAN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2024
Last Update Date: 04/30/2024
Certification Date: 04/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 LONGLEAF PINE PKWY STE 200
ST JOHNS FL
32259-7529
US

IV. Provider business mailing address

4800 BELFORT RD
JACKSONVILLE FL
32256-6004
US

V. Phone/Fax

Practice location:
  • Phone: 904-652-0800
  • Fax:
Mailing address:
  • Phone: 904-398-7205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11031165
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: