1598272650 NPI number — NORTHWEST FLORIDA HEALTHCARE, INC.

Table of content: VONETTA BUTLER BLAKELY LCSW (NPI 1083219588)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598272650 NPI number — NORTHWEST FLORIDA HEALTHCARE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHWEST FLORIDA HEALTHCARE, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1598272650
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/10/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1360 BRICKYARD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHIPLEY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32428-6303
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-638-1610
Provider Business Mailing Address Fax Number:
850-638-0622

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1410 BRICKYARD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHIPLEY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32428-5966
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-638-3400
Provider Business Practice Location Address Fax Number:
850-638-9611
Provider Enumeration Date:
01/10/2018

Additional Information

Authorized Official

Authorized Official Last Name:
MORGAN
Authorized Official First Name:
MARCEY
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
850-415-8127

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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