MEDICARE: JANE A PRATT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	R9474	OTHER	FL	BCBS PROVIDER NUMBER

General Provider Information

NPI Number	:	1417931585
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JANE A PRATT

Provider Business Mailing Address
First Line	:	219 CREWILLA DR NW
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32548-3947
Country	:	US
Telephone Number	:	850-581-7700
Fax Number	:	850-244-5342

Provider Business Practice Location Address
First Line	:	219 CREWILLA DR NW
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32548-3947
Country	:	US
Telephone Number	:	850-581-7700
Fax Number	:	850-244-5342

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/02/2005
Last Update Date	:	07/09/2007

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Directions to “ JANE A PRATT ” Practice Location

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