Provider Demographics
NPI:1124070446
Name:BAZALDUA, MARY MARGARET (ARNP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:MARGARET
Last Name:BAZALDUA
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4049 MCGIRTS BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-4340
Mailing Address - Country:US
Mailing Address - Phone:812-480-3420
Mailing Address - Fax:
Practice Address - Street 1:6817 SOUTHPOINT PKWY
Practice Address - Street 2:SUITE 2304
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-6282
Practice Address - Country:US
Practice Address - Phone:904-296-1874
Practice Address - Fax:904-296-1877
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9234572363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAPRN 9234572OtherNURSE PRACTITIONER LICENS
FL215710Medicare ID - Type Unspecified
FLAPRN 9234572OtherNURSE PRACTITIONER LICENS