MEDICARE: MS. JOHNNA LYNN DETTIS ARNP

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	163WP2201X	Ambulatory Care Registered Nurse	1244422	FL
2	363LF0000X	Family Nurse Practitioner	1244422	FL
3	363LW0102X	Women's Health Nurse Practitioner	1244422	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1700871662
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JOHNNA LYNN DETTIS ARNP

Provider Business Mailing Address
First Line	:	3487 BROADWAY AVE.
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33901-7213
Country	:	US
Telephone Number	:	239-334-9555
Fax Number	:	239-334-2832

Provider Business Practice Location Address
First Line	:	3487 BROADWAY AVE.
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33901-7213
Country	:	US
Telephone Number	:	239-334-9555
Fax Number	:	239-334-2832

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

Provider Enumeration Date	:	09/16/2005
Last Update Date	:	07/24/2013

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