MEDICARE: HEATHER LYNN PELT APRN-C

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	363LP2300X	Primary Care Nurse Practitioner	11024759	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1518642511
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEATHER LYNN PELT APRN-C

Provider Business Mailing Address
First Line	:	506 N HUBBARD ST
Second Line	:
City	:	BONIFAY
State	:	FL
Zip	:	32425-2022
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	102 MEDICAL CENTER DR
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32405-4907
Country	:	US
Telephone Number	:	850-913-1666
Fax Number	:

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

Provider Enumeration Date	:	06/16/2023
Last Update Date	:	06/16/2023

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