Healthcare Provider Details

I. General information

NPI: 1447847983
Provider Name (Legal Business Name): DR BOTTKOL APRN DNP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2020
Last Update Date: 12/30/2020
Certification Date: 12/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 LASIESTA DRIVE
MEXICO BEACH FL
32456
US

IV. Provider business mailing address

406 LASIESTA DRIVE
MEXICO BEACH FL
32456
US

V. Phone/Fax

Practice location:
  • Phone: 850-381-1866
  • Fax:
Mailing address:
  • Phone: 850-381-1866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MRS. CHRISTINE BOTTKOL
Title or Position: OWNER
Credential: APRN DNP
Phone: 850-381-1866