Healthcare Provider Details

I. General information

NPI: 1023617420
Provider Name (Legal Business Name): JOHN BERTRAM GARRETT IV MSN, APRN, FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2020
Last Update Date: 10/19/2020
Certification Date: 10/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5079 GARRETT RD
MALONE FL
32445-3409
US

IV. Provider business mailing address

5079 GARRETT RD
MALONE FL
32445-3409
US

V. Phone/Fax

Practice location:
  • Phone: 505-557-3761
  • Fax:
Mailing address:
  • Phone: 850-557-3761
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAPRN11008985
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: