Healthcare Provider Details

I. General information

NPI: 1588246714
Provider Name (Legal Business Name): MISHELA GEVORKYAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2021
Last Update Date: 02/24/2025
Certification Date: 02/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1046 MAR WALT DR # 200
FORT WALTON BEACH FL
32547-6645
US

IV. Provider business mailing address

92 SW 3RD ST
MIAMI FL
33130-2998
US

V. Phone/Fax

Practice location:
  • Phone: 850-243-2229
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11011131
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number11011131
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: