Healthcare Provider Details

I. General information

NPI: 1598097768
Provider Name (Legal Business Name): GLORIA JEAN LELAIDIER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2010
Last Update Date: 02/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72 SOUTH ST
ST AUGUSTINE FL
32084-5127
US

IV. Provider business mailing address

PO BOX 3123
ST AUGUSTINE FL
32085-3123
US

V. Phone/Fax

Practice location:
  • Phone: 904-824-4990
  • Fax: 904-824-2226
Mailing address:
  • Phone: 904-824-4990
  • Fax: 904-824-2226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License NumberARNP1634442
License Number StateFL

VIII. Authorized Official

Name: GLORIA LELAIDIER
Title or Position: PRESIDENT
Credential: ARNP, CNM
Phone: 904-829-2686