=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275144362
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA ANNE BRULAND APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2020
-----------------------------------------------------
Last Update Date | 05/26/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1348 S 18TH ST STE 230
-----------------------------------------------------
City | FERNANDINA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32034-4785
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-277-2003
-----------------------------------------------------
Fax | 904-277-2006
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2421
-----------------------------------------------------
City | SALT LAKE CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84110-2421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-202-1032
-----------------------------------------------------
Fax | 904-376-4107
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 11006630
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | APRN11006630
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | APRN11006630
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------