Healthcare Provider Details

I. General information

NPI: 1164239968
Provider Name (Legal Business Name): MATTHEW ROBERT BAXTER PMHNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2024
Last Update Date: 03/10/2026
Certification Date: 03/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 WILLIS AVE
DAYTONA BEACH FL
32114-2810
US

IV. Provider business mailing address

150 MAGNOLIA AVE
DAYTONA BEACH FL
32114-4304
US

V. Phone/Fax

Practice location:
  • Phone: 800-539-4228
  • Fax:
Mailing address:
  • Phone: 800-859-4228
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN11044631
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9287274
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: