Provider Demographics
NPI:1871894972
Name:GERISOURCE
Entity type:Organization
Organization Name:GERISOURCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:H
Authorized Official - Last Name:CLAYMAN
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:904-252-5265
Mailing Address - Street 1:11812 CRUSSELLE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-0876
Mailing Address - Country:US
Mailing Address - Phone:904-252-5265
Mailing Address - Fax:
Practice Address - Street 1:11812 CRUSSELLE DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-0876
Practice Address - Country:US
Practice Address - Phone:904-252-5265
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-06
Last Update Date:2010-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9260038363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Single Specialty