Provider Demographics
NPI:1073762548
Name:NORTH EAST FLORIDA ENDOCRINE DIABETES
Entity Type:Organization
Organization Name:NORTH EAST FLORIDA ENDOCRINE DIABETES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ARNP
Authorized Official - Prefix:MR
Authorized Official - First Name:RODEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GLORIA
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:904-384-2240
Mailing Address - Street 1:915 W MONROE ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-1177
Mailing Address - Country:US
Mailing Address - Phone:904-384-2240
Mailing Address - Fax:904-384-6055
Practice Address - Street 1:915 W MONROE ST
Practice Address - Street 2:SUITE 200
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-1177
Practice Address - Country:US
Practice Address - Phone:904-384-2240
Practice Address - Fax:904-384-6055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-09
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2968382363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty