Provider Demographics
NPI:1558526145
Name:LIVINGSTON-HODGES, GAYNELL L (MEDICAID PROVIDER)
Entity Type:Individual
Prefix:MS
First Name:GAYNELL
Middle Name:L
Last Name:LIVINGSTON-HODGES
Suffix:
Gender:F
Credentials:MEDICAID PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 BROAD STN
Mailing Address - Street 2:SUITE # 202
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32202
Mailing Address - Country:US
Mailing Address - Phone:904-358-9487
Mailing Address - Fax:
Practice Address - Street 1:1320 BROAD ST
Practice Address - Street 2:SUITE # 202
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32202-3902
Practice Address - Country:US
Practice Address - Phone:904-358-9487
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-23
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6933335-96172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker