Provider Demographics
NPI:1700806619
Name:GOULET, WALDEMAR MELVIN JR (FNP-BC, NP-C)
Entity Type:Individual
Prefix:MR
First Name:WALDEMAR
Middle Name:MELVIN
Last Name:GOULET
Suffix:JR
Gender:M
Credentials:FNP-BC, NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1722 KINGSWOOD RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-5429
Mailing Address - Country:US
Mailing Address - Phone:904-673-2207
Mailing Address - Fax:
Practice Address - Street 1:3505 UNIVERSITY BLVD W
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-2130
Practice Address - Country:US
Practice Address - Phone:904-438-7683
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY322401363LF0000X
FLARNP9196116363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG3399XMedicare PIN
FLG3399YMedicare PIN