Provider Demographics
NPI:1760107940
Name:RABENOLD, JENNIE (NP)
Entity Type:Individual
Prefix:
First Name:JENNIE
Middle Name:
Last Name:RABENOLD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1705 SANCTUARY WAY
Mailing Address - Street 2:
Mailing Address - City:FLEMING ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32003-4986
Mailing Address - Country:US
Mailing Address - Phone:904-599-9085
Mailing Address - Fax:
Practice Address - Street 1:1705 SANCTUARY WAY
Practice Address - Street 2:
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003-4986
Practice Address - Country:US
Practice Address - Phone:904-599-9085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-10
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11013684363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily