Provider Demographics
NPI:1730335100
Name:LELAIDIER, GLORIA J (ARNP, CNMW)
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:J
Last Name:LELAIDIER
Suffix:
Gender:F
Credentials:ARNP, CNMW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 16568
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32245-6568
Mailing Address - Country:US
Mailing Address - Phone:904-472-2300
Mailing Address - Fax:904-472-2330
Practice Address - Street 1:301 HEALTH PARK BLVD
Practice Address - Street 2:STE 219
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5795
Practice Address - Country:US
Practice Address - Phone:904-819-9898
Practice Address - Fax:904-819-9594
Is Sole Proprietor?:No
Enumeration Date:2008-08-17
Last Update Date:2015-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 1634442367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY3038OtherBCBS
FL000392200Medicaid
FLBE668YMedicare PIN
FLBE668XMedicare PIN