MEDICARE: MRS. MARCHETA S NIX OT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	2588	FL

General Provider Information

NPI Number	:	1548592868
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARCHETA S NIX OT

Provider Business Mailing Address
First Line	:	1153 GULF BREEZE PKWY
Second Line	:
City	:	GULF BREEZE
State	:	FL
Zip	:	32561-7807
Country	:	US
Telephone Number	:	850-932-6382
Fax Number	:	850-932-9225

Provider Business Practice Location Address
First Line	:	1008 AIRPORT RD
Second Line	:	SUITE A
City	:	DESTIN
State	:	FL
Zip	:	32541-2823
Country	:	US
Telephone Number	:	850-837-3349
Fax Number	:	850-837-3158

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/11/2010
Last Update Date	:	02/11/2010

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