Provider Demographics
NPI:1053393421
Name:HARRIS, MARCIANN (NP)
Entity type:Individual
Prefix:
First Name:MARCIANN
Middle Name:
Last Name:HARRIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4205 BELFORT RD STE 4015
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-3623
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4205 BELFORT RD STE 2069
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-1471
Practice Address - Country:US
Practice Address - Phone:904-450-8500
Practice Address - Fax:904-296-0279
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2022-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO89947363LA2200X
FLAPRN11002870363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
COP00221664Medicare PIN
COQ07360Medicare UPIN
COC543058Medicare PIN