Provider Demographics
NPI:1497263297
Name:CUNNINGHAM, SALACIA
Entity Type:Individual
Prefix:
First Name:SALACIA
Middle Name:
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5959 FORT CAROLINE RD APT 3102
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32277-1863
Mailing Address - Country:US
Mailing Address - Phone:850-510-9142
Mailing Address - Fax:
Practice Address - Street 1:10199 SOUTHSIDE BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-0758
Practice Address - Country:US
Practice Address - Phone:850-510-9142
Practice Address - Fax:850-510-9142
Is Sole Proprietor?:No
Enumeration Date:2018-01-15
Last Update Date:2018-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9334560363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health