1942859251 NPI number — CHRISTINE O'REILLY BLANK CAA

Table of content: CHRISTINE O'REILLY BLANK CAA (NPI 1942859251)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942859251 NPI number — CHRISTINE O'REILLY BLANK CAA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLANK
Provider First Name:
CHRISTINE
Provider Middle Name:
O'REILLY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CAA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
O'REILLY
Provider Other First Name:
CHRISTINE
Provider Other Middle Name:
KATHERINE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CAA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1942859251
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/24/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
96 RAINBOW TROUT LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PONTE VEDRA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32081-1213
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-441-9395
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 SHIRCLIFF WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32204-4748
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-308-7300
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/09/2019

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: 367H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 104694300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".