Provider Demographics
NPI:1831689678
Name:SUMMERS, MILLELY JOSEFINA
Entity type:Individual
Prefix:
First Name:MILLELY
Middle Name:JOSEFINA
Last Name:SUMMERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1689 EAGLE HARBOR PKWY
Mailing Address - Street 2:STE B
Mailing Address - City:FLEMING ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32003-4817
Mailing Address - Country:US
Mailing Address - Phone:904-388-3357
Mailing Address - Fax:904-384-5746
Practice Address - Street 1:6444 BEACH BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-2891
Practice Address - Country:US
Practice Address - Phone:904-805-9600
Practice Address - Fax:904-805-0084
Is Sole Proprietor?:No
Enumeration Date:2018-05-17
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9354385363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLARNP9354385OtherMEDICAL LICENSE