Healthcare Provider Details

I. General information

NPI: 1467278895
Provider Name (Legal Business Name): MICAELA HARRISON DNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICAELA HAYTON RN

II. Dates (important events)

Enumeration Date: 12/02/2024
Last Update Date: 12/02/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3055 COUNTY ROAD 210 W STE 105
ST JOHNS FL
32259-7001
US

IV. Provider business mailing address

150 SEAPORT BREEZE RD
SAINT AUGUSTINE FL
32095-0138
US

V. Phone/Fax

Practice location:
  • Phone: 904-223-9100
  • Fax:
Mailing address:
  • Phone: 720-301-7672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number11035256
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: