Healthcare Provider Details

I. General information

NPI: 1295587293
Provider Name (Legal Business Name): RUSSELL KEVIN BROXSON JR. FNP BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2024
Last Update Date: 04/16/2024
Certification Date: 04/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14114 ALABAMA ST
JAY FL
32565-1219
US

IV. Provider business mailing address

5228 MEDICINE BOW ST
MILTON FL
32570-8149
US

V. Phone/Fax

Practice location:
  • Phone: 850-675-8000
  • Fax:
Mailing address:
  • Phone: 850-449-4801
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11031992
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: