Provider Demographics
NPI:1598432338
Name:SCULLY, SOPHIA FORSYTH (CAA)
Entity Type:Individual
Prefix:MRS
First Name:SOPHIA
Middle Name:FORSYTH
Last Name:SCULLY
Suffix:
Gender:F
Credentials:CAA
Other - Prefix:
Other - First Name:SOPHIA
Other - Middle Name:FORSYTH
Other - Last Name:BRACKEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CAA
Mailing Address - Street 1:2304 LATRIUM CIR N
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32082-2920
Mailing Address - Country:US
Mailing Address - Phone:904-874-9091
Mailing Address - Fax:
Practice Address - Street 1:1 SHIRCLIFF WAY
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4748
Practice Address - Country:US
Practice Address - Phone:904-308-7300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-29
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAA658367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant