1649381880 NPI number — DR. HEATHER WILFONG SVENSON M.D.

Table of content: LAUREN KRIETER PA-C (NPI 1598274425)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649381880 NPI number — DR. HEATHER WILFONG SVENSON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SVENSON
Provider First Name:
HEATHER
Provider Middle Name:
WILFONG
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TAYLOR
Provider Other First Name:
HEATHER
Provider Other Middle Name:
ANNE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1649381880
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/02/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13626 SHIPWATCH DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32225-5402
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-399-3824
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4215 PLANTATION OAKS BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORANGE PARK
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32065-3641
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-633-0820
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  050841 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: ME119017 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 649597456B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 649597456A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000926087C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 113741600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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