Provider Demographics
NPI:1396117693
Name:REISDORF, SONIA RAE (ARNP)
Entity type:Individual
Prefix:
First Name:SONIA
Middle Name:RAE
Last Name:REISDORF
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:PO BOX 860069
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-0069
Mailing Address - Country:US
Mailing Address - Phone:904-819-4082
Mailing Address - Fax:904-819-5056
Practice Address - Street 1:381 PALM COAST PKWY SW UNIT 2
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-4782
Practice Address - Country:US
Practice Address - Phone:386-232-8089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-26
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9318208363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner