Provider Demographics
NPI:1033776539
Name:HALVERSON, GREGG STEVEN (APRN)
Entity Type:Individual
Prefix:
First Name:GREGG
Middle Name:STEVEN
Last Name:HALVERSON
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1542 KINGSLEY AVE STE 136
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4547
Mailing Address - Country:US
Mailing Address - Phone:904-458-7780
Mailing Address - Fax:
Practice Address - Street 1:1542 KINGSLEY AVE STE 136
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4547
Practice Address - Country:US
Practice Address - Phone:904-458-7780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-21
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2021033954363LP0808X
FL11001570363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health