Healthcare Provider Details

I. General information

NPI: 1265712343
Provider Name (Legal Business Name): JACK EDWARD CONEBY RNBC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2011
Last Update Date: 08/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3820 CENTRAL AVE
ST PETERSBURG FL
33711-1237
US

IV. Provider business mailing address

3820 CENTRAL AVE
ST PETERSBURG FL
33711-1237
US

V. Phone/Fax

Practice location:
  • Phone: 727-543-9416
  • Fax:
Mailing address:
  • Phone: 727-543-9416
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberRN1461352
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: