Provider Demographics
NPI:1811369911
Name:FALLON, KERRIE
Entity Type:Individual
Prefix:
First Name:KERRIE
Middle Name:
Last Name:FALLON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KERRIE
Other - Middle Name:ANN
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3599 UNIVERSITY BLVD S
Mailing Address - Street 2:BLDG 300
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-4252
Mailing Address - Country:US
Mailing Address - Phone:904-399-5550
Mailing Address - Fax:904-346-4334
Practice Address - Street 1:3599 UNIVERSITY BLVD S
Practice Address - Street 2:BLDG 300
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4252
Practice Address - Country:US
Practice Address - Phone:904-399-5550
Practice Address - Fax:904-346-4334
Is Sole Proprietor?:No
Enumeration Date:2015-10-28
Last Update Date:2017-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9109073363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant