Provider Demographics
NPI:1437813730
Name:LOVE, JAMES RUSSELL
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:RUSSELL
Last Name:LOVE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JIMMY
Other - Middle Name:RUSSELL
Other - Last Name:LOVE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4717 AVON LN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-7503
Mailing Address - Country:US
Mailing Address - Phone:904-514-3532
Mailing Address - Fax:
Practice Address - Street 1:4717 AVON LN
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-7503
Practice Address - Country:US
Practice Address - Phone:904-514-3532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-24
Last Update Date:2021-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11015943363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily