Basic Information
| Provider Information | |||||||||
| NPI: | 1306021647 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH FLORIDA/SOUTH GEORGIA VETERAN'S HEALTH ADMINISTRATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 619 S MARION AVE | ||||||||
| Address2: | |||||||||
| City: | LAKE CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320255808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3867553106 | ||||||||
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| Practice Location | |||||||||
| Address1: | 619 S MARION AVE | ||||||||
| Address2: | |||||||||
| City: | LAKE CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320255808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3867553016 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2008 | ||||||||
| LastUpdateDate: | 01/06/2008 | ||||||||
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| AuthorizedOfficialLastName: | CORNETT | ||||||||
| AuthorizedOfficialFirstName: | LORI | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | LICENSED PRACTICAL NURSE | ||||||||
| AuthorizedOfficialTelephone: | 3867553016 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | LPN | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282E00000X | PN 5161386 | FL | Y | Hospitals | Long Term Care Hospital |
No ID Information.