MEDICARE: SONIA RAE REISDORF ARNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	9318208	FL

General Provider Information

NPI Number	:	1396117693
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SONIA RAE REISDORF ARNP

Provider Business Mailing Address
First Line	:	PO BOX 860069
Second Line	:
City	:	ST AUGUSTINE
State	:	FL
Zip	:	32086-0069
Country	:	US
Telephone Number	:	904-819-4082
Fax Number	:	904-819-5056

Provider Business Practice Location Address
First Line	:	381 PALM COAST PKWY SW UNIT 2
Second Line	:
City	:	PALM COAST
State	:	FL
Zip	:	32137-4782
Country	:	US
Telephone Number	:	386-232-8089
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/26/2015
Last Update Date	:	12/02/2024

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