Provider Demographics
NPI:1922670306
Name:WRIGHT, ANNIE JEANETTE (PA-C)
Entity Type:Individual
Prefix:
First Name:ANNIE
Middle Name:JEANETTE
Last Name:WRIGHT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 BEACH BLVD APT 1101
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-5328
Mailing Address - Country:US
Mailing Address - Phone:678-850-6425
Mailing Address - Fax:
Practice Address - Street 1:14540 OLD SAINT AUGUSTINE RD # SR2571
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-7418
Practice Address - Country:US
Practice Address - Phone:904-886-2251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-14
Last Update Date:2022-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1177817363A00000X
FLPA9116697363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant