MEDICARE: DR. MISTY V GADDIS DNP

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	363LF0000X	Family Nurse Practitioner	9194155	FL

General Provider Information

NPI Number	:	1841852266
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MISTY V GADDIS DNP

Provider Business Mailing Address
First Line	:	1729 NW SAINT LUCIE WEST BLVD # 1128
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34986-2501
Country	:	US
Telephone Number	:	561-985-0342
Fax Number	:

Provider Business Practice Location Address
First Line	:	3281 SW COHUTTA ST
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34953-4647
Country	:	US
Telephone Number	:	561-985-0342
Fax Number	:

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

Provider Enumeration Date	:	07/05/2019
Last Update Date	:	03/17/2026

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