Provider Demographics
NPI:1689178667
Name:PROVOST-DUKES, GEORGETTE LOUISE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:GEORGETTE
Middle Name:LOUISE
Last Name:PROVOST-DUKES
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3110 WHITE HERON TRL
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-1644
Mailing Address - Country:US
Mailing Address - Phone:407-719-5723
Mailing Address - Fax:
Practice Address - Street 1:4241 BAYMEADOWS RD STE 6
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-4673
Practice Address - Country:US
Practice Address - Phone:407-719-5723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-22
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9168198363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty