Provider Demographics
NPI:1003411232
Name:ADDISON, GREGORY JOHN (RN)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:JOHN
Last Name:ADDISON
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5143 CHOCTAW AVE
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32507-8712
Mailing Address - Country:US
Mailing Address - Phone:559-410-0800
Mailing Address - Fax:
Practice Address - Street 1:5143 CHOCTAW AVE
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32507-8712
Practice Address - Country:US
Practice Address - Phone:559-410-0800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-04
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9216433163W00000X
FL11011747363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse