Provider Demographics
NPI:1952027435
Name:HARRELL, PATRICIA
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:HARRELL
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 1:1168 CARMONA PLACE
Mailing Address - Street 2:
Mailing Address - City:ST. AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092
Mailing Address - Country:US
Mailing Address - Phone:904-859-6294
Mailing Address - Fax:
Practice Address - Street 1:1168 CARMONA PLACE
Practice Address - Street 2:
Practice Address - City:ST. AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092
Practice Address - Country:US
Practice Address - Phone:904-859-6294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-17
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL574897240171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach