Basic Information
| Provider Information | |||||||||
| NPI: | 1598097768 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GLORIA JEAN LELAIDIER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3123 | ||||||||
| Address2: | |||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320853123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048244990 | ||||||||
| FaxNumber: | 9048242226 | ||||||||
| Practice Location | |||||||||
| Address1: | 72 SOUTH ST | ||||||||
| Address2: | |||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320845127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048244990 | ||||||||
| FaxNumber: | 9048242226 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2010 | ||||||||
| LastUpdateDate: | 02/12/2010 | ||||||||
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| AuthorizedOfficialLastName: | LELAIDIER | ||||||||
| AuthorizedOfficialFirstName: | GLORIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9048292686 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | ARNP, CNM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WR0006X | ARNP1634442 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Registered Nurse First Assistant |
ID Information
| ID | Type | State | Issuer | Description | 000392200 | 05 | FL | MEDICAID |