=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487439394
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 360 BLUE FAMILY MEDICAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2023
-----------------------------------------------------
Last Update Date | 09/16/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 949 JENKS AVE STE 6
-----------------------------------------------------
City | PANAMA CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32401-2584
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-853-0809
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 949 JENKS AVE STE 6
-----------------------------------------------------
City | PANAMA CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32401-2584
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-853-0809
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EMPLOYEE
-----------------------------------------------------
Name | DR. SAMANTHA BLUE
-----------------------------------------------------
Credential | DNP, APRN, FNP-BC,
-----------------------------------------------------
Telephone | 850-319-7345
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------