Healthcare Provider Details

I. General information

NPI: 1760485189
Provider Name (Legal Business Name): STANLEY FRANKLIN WHITTAKER ANP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2005
Last Update Date: 10/29/2020
Certification Date: 10/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20274 CENTRAL AVE W
BLOUNTSTOWN FL
32424-1957
US

IV. Provider business mailing address

6294 NW TORREYA PARK RD
BRISTOL FL
32321-2412
US

V. Phone/Fax

Practice location:
  • Phone: 850-353-7689
  • Fax: 850-674-8889
Mailing address:
  • Phone: 850-643-2427
  • Fax: 850-643-1270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number587
License Number StateAK
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP2582432
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: