Provider Demographics
NPI:1912188657
Name:VANETTEN-RUNTE, AUDREY (PHARMD, PA-C)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:VANETTEN-RUNTE
Suffix:
Gender:F
Credentials:PHARMD, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 66087
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32065-0019
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:430 COLLEGE DR
Practice Address - Street 2:SUITES 100, 102, 104
Practice Address - City:MIDDLEBURG
Practice Address - State:FL
Practice Address - Zip Code:32068-8530
Practice Address - Country:US
Practice Address - Phone:904-730-5774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-23
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104243363A00000X
FLPS33649183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant