1790095479 NPI number — MRS. RACHEL MARIA REID PA-C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790095479 NPI number — MRS. RACHEL MARIA REID PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REID
Provider First Name:
RACHEL
Provider Middle Name:
MARIA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SOUTHERLAND
Provider Other First Name:
RACHEL
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1790095479
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/29/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
104 LAS ROBLAS GRANDE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANTA ROSA BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32459-2603
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-519-6773
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1001 COLLEGE BLVD W STE I
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NICEVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32578-1049
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-842-4563
Provider Business Practice Location Address Fax Number:
850-842-4606
Provider Enumeration Date:
10/15/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA08626 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA968 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA9107878 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: PA9107878 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 022751600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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