=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255959474
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TRACEY FITZGERALD LPN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2020
-----------------------------------------------------
Last Update Date | 07/14/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 50 N LAURA ST STE 2560
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32202-3664
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-525-0308
-----------------------------------------------------
Fax | 904-302-8749
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 50 N LAURA ST STE 2560
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32202-3664
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-440-3602
-----------------------------------------------------
Fax | 904-302-8749
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | PN5224459
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------