Provider Demographics
NPI:1073292785
Name:DETTLINGER, GRETCHEN DUBRIE (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:DUBRIE
Last Name:DETTLINGER
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2537 OAK STREAM DR
Mailing Address - Street 2:
Mailing Address - City:GREEN COVE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32043-8663
Mailing Address - Country:US
Mailing Address - Phone:313-600-9291
Mailing Address - Fax:
Practice Address - Street 1:2537 OAK STREAM DR
Practice Address - Street 2:
Practice Address - City:GREEN COVE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32043-8663
Practice Address - Country:US
Practice Address - Phone:313-600-9291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-12
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11027382363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty