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General NPI Number Information
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NPI Number | 1962082693
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Entity Type | Individual
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Provider Name | DIVINA MERCADO PRIDHAM PMHNP
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Gender | Female
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Dates
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Enumeration Date | 04/08/2021
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Last Update Date | 06/18/2024
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Provider Practice Location Address
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Address Line | 555 STOCKTON ST
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City | JACKSONVILLE
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State | FL
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Zip | 32204-2534
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Country | US
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Telephone | 904-547-9468
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Fax |
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Provider Business Mailing Address
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Address Line | 1335 RYAR RD
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City | JACKSONVILLE
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State | FL
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Zip | 32216-2802
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Country | US
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Telephone | 904-651-4525
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | APRN11012297
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License Number State | FL
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