Provider Demographics
NPI:1194070367
Name:PROVO, AIMEE LYNN (BS)
Entity type:Individual
Prefix:MISS
First Name:AIMEE
Middle Name:LYNN
Last Name:PROVO
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4263 LOSCO RD APT 1122
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257-1452
Mailing Address - Country:US
Mailing Address - Phone:904-642-9100
Mailing Address - Fax:904-641-6529
Practice Address - Street 1:11820 BEACH BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-6670
Practice Address - Country:US
Practice Address - Phone:904-642-9100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-13
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker