=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396117693
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SONIA RAE REISDORF ARNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2015
-----------------------------------------------------
Last Update Date | 12/02/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 381 PALM COAST PKWY SW UNIT 2
-----------------------------------------------------
City | PALM COAST
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32137-4782
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-232-8089
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 860069
-----------------------------------------------------
City | ST AUGUSTINE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32086-0069
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-819-4082
-----------------------------------------------------
Fax | 904-819-5056
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 9318208
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------