Provider Demographics
NPI:1164751707
Name:DR. MARY'S PLACE
Entity Type:Organization
Organization Name:DR. MARY'S PLACE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC ARNP
Authorized Official - Prefix:MS
Authorized Official - First Name:CARA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:D'AMICO
Authorized Official - Suffix:
Authorized Official - Credentials:C-PNP, ARNP
Authorized Official - Phone:904-642-6100
Mailing Address - Street 1:4051 ATLANTIC BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-2036
Mailing Address - Country:US
Mailing Address - Phone:904-393-4700
Mailing Address - Fax:904-493-9700
Practice Address - Street 1:4051 ATLANTIC BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-2036
Practice Address - Country:US
Practice Address - Phone:904-393-4700
Practice Address - Fax:904-493-9700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-10
Last Update Date:2011-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9271693363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty