Provider Demographics
NPI:1518586403
Name:BOOTH, GYNNEKIA MARIE
Entity Type:Individual
Prefix:
First Name:GYNNEKIA
Middle Name:MARIE
Last Name:BOOTH
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 1:12700 BARTRAM PARK BLVD APT 2314
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-5449
Mailing Address - Country:US
Mailing Address - Phone:813-420-7929
Mailing Address - Fax:
Practice Address - Street 1:4873 BELLE TERRE PKWY
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-8696
Practice Address - Country:US
Practice Address - Phone:386-864-8313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-10
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLDN25483122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program