=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235865403
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JARRETT SCULLY APRN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2022
-----------------------------------------------------
Last Update Date | 08/23/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 71 MARY ESTHER BLVD
-----------------------------------------------------
City | MARY ESTHER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32569-1967
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-776-3874
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 71 MARY ESTHER BLVD
-----------------------------------------------------
City | MARY ESTHER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32569-1967
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-776-3874
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 11021089
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------