Provider Demographics
NPI:1962082693
Name:PRIDHAM, DIVINA MERCADO (PMHNP)
Entity type:Individual
Prefix:MRS
First Name:DIVINA
Middle Name:MERCADO
Last Name:PRIDHAM
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1335 RYAR RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-2802
Mailing Address - Country:US
Mailing Address - Phone:904-651-4525
Mailing Address - Fax:
Practice Address - Street 1:555 STOCKTON ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-2534
Practice Address - Country:US
Practice Address - Phone:904-547-9468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-08
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11012297363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health