Healthcare Provider Details

I. General information

NPI: 1093790875
Provider Name (Legal Business Name): MARILYN T SPRENKLE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 01/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36468 EMERALD COAST PARKWAY UNIT 2101
DESTIN FL
32541
US

IV. Provider business mailing address

1005 MAR WALT DR
FORT WALTON BEACH FL
32547-6707
US

V. Phone/Fax

Practice location:
  • Phone: 850-659-6556
  • Fax: 850-249-1308
Mailing address:
  • Phone: 850-863-8100
  • Fax: 850-863-2303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME87333
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: