Healthcare Provider Details

I. General information

NPI: 1598515355
Provider Name (Legal Business Name): BRIANA RAE TOOTHAKER FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2024
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350G RACETRACK RD NW
FORT WALTON BEACH FL
32547-1699
US

IV. Provider business mailing address

350G RACETRACK RD NW
FORT WALTON BEACH FL
32547-1699
US

V. Phone/Fax

Practice location:
  • Phone: 850-374-3125
  • Fax: 850-226-5544
Mailing address:
  • Phone: 850-374-3125
  • Fax: 850-226-5544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2024004878
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11042188
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: