Healthcare Provider Details

I. General information

NPI: 1912529116
Provider Name (Legal Business Name): EMERALD COAST SLEEP DIAGNOSTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2020
Last Update Date: 10/26/2022
Certification Date: 10/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 MCKENZIE AVE
PANAMA CITY FL
32401-3062
US

IV. Provider business mailing address

620 MCKENZIE AVE
PANAMA CITY FL
32401-3062
US

V. Phone/Fax

Practice location:
  • Phone: 850-518-7378
  • Fax: 850-640-4187
Mailing address:
  • Phone: 850-518-7378
  • Fax: 850-640-4187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0012X
TaxonomySleep Medicine (Otolaryngology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: AMBER MCKENZIE
Title or Position: AUTHORIZED OFFICIAL
Credential: ARNP
Phone: 850-866-9990