Provider Demographics
NPI:1043518756
Name:MAPLE, TERA DANIELLS (ARNP)
Entity Type:Individual
Prefix:
First Name:TERA
Middle Name:DANIELLS
Last Name:MAPLE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4205 BELFORT RD STE 4015
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-3623
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1658 ST VINCENTS WAY STE 100
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG
Practice Address - State:FL
Practice Address - Zip Code:32068-8459
Practice Address - Country:US
Practice Address - Phone:904-602-4311
Practice Address - Fax:904-354-1340
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-03
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9264398363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006292300Medicaid
GA003126038AMedicaid
GA003126038AMedicaid