MEDICARE: DIANA DUDENKOVA LONGACRE APRN

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	363LF0000X	Family Nurse Practitioner	APRN11000344	FL

General Provider Information

NPI Number	:	1629532080
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANA DUDENKOVA LONGACRE APRN

Provider Business Mailing Address
First Line	:	10915 BAYMEADOWS RD STE 104
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-9131
Country	:	US
Telephone Number	:	904-683-6924
Fax Number	:

Provider Business Practice Location Address
First Line	:	10915 BAYMEADOWS RD STE 104
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-9131
Country	:	US
Telephone Number	:	904-683-6924
Fax Number	:

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

Provider Enumeration Date	:	01/29/2019
Last Update Date	:	01/29/2019

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