Basic Information
| Provider Information | |||||||||
| NPI: | 1790223386 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PEREZ | ||||||||
| FirstName: | RAQUEL | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 45443 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841450443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042021032 | ||||||||
| FaxNumber: | 9043764107 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 BISHOP ESTATES RD | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32259 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042872794 | ||||||||
| FaxNumber: | 9042875362 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2017 | ||||||||
| LastUpdateDate: | 09/16/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | ARNP9434464 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | APRN9434464 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 022863100 | 05 | FL | MEDICAID |