MEDICARE: MRS. MARY JEAN MARIE MIDDLETON FNP-C

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	APRN11012268	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	:	1972009629
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARY JEAN MARIE MIDDLETON FNP-C

Provider Business Mailing Address
First Line	:	1005 MAR WALT DR
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32547-6707
Country	:	US
Telephone Number	:	850-863-8100
Fax Number	:	850-863-4152

Provider Business Practice Location Address
First Line	:	990 AIRPORT RD
Second Line	:
City	:	DESTIN
State	:	FL
Zip	:	32541-2820
Country	:	US
Telephone Number	:	850-269-6400
Fax Number	:	850-654-9581

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

Provider Enumeration Date	:	04/02/2018
Last Update Date	:	03/04/2022

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