{
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"FirstLineMailingAddress": "1680 OSCEOLA ELEMENTARY SCHOOL ROAD",
"SecondLineMailingAddress": "SUITE A",
"MailingAddressCityName": "ST AUGUSTINE",
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"MailingAddressPostalCode": "32084",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "904-824-7476",
"MailingAddressFaxNumber": "904-824-7870",
"FirstLinePracticeLocationAddress": "1680 OSCEOLA ELEMENTARY SCHOOL ROAD",
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"PracticeLocationAddressFaxNumber": "904-824-7870",
"EnumerationDate": "02/21/2007",
"LastUpdateDate": "10/22/2007",
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"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
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"AuthorizedOfficialLastName": "FAIRCLOTH",
"AuthorizedOfficialFirstName": "JENNIFER",
"AuthorizedOfficialMiddleName": "RAE",
"AuthorizedOfficialTitle": "OFFICE MANAGER",
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"AuthorizedOfficialCredential": "L P N",
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"Taxonomies": {
"Taxonomy": {
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"TaxonomyName": "Specialist",
"LicenseNumber": "ME0066989",
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"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
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"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}