Provider Demographics
NPI:1669939286
Name:FISHER, ANTHONY
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:FISHER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:193 BRADFORD LAKE CIR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-0103
Mailing Address - Country:US
Mailing Address - Phone:904-697-8553
Mailing Address - Fax:
Practice Address - Street 1:193 BRADFORD LAKE CIR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-0103
Practice Address - Country:US
Practice Address - Phone:904-697-8553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-01
Last Update Date:2019-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP1600X
FLRN9356853163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral