Provider Demographics
NPI:1073372124
Name:SALT AND IVY GULF LLC
Entity Type:Organization
Organization Name:SALT AND IVY GULF LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER/ OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRITTANY
Authorized Official - Middle Name:GARDNER
Authorized Official - Last Name:MCCROAN
Authorized Official - Suffix:
Authorized Official - Credentials:APRN-C
Authorized Official - Phone:850-357-8192
Mailing Address - Street 1:204 CORAL DR
Mailing Address - Street 2:
Mailing Address - City:PORT ST JOE
Mailing Address - State:FL
Mailing Address - Zip Code:32456-6257
Mailing Address - Country:US
Mailing Address - Phone:850-357-8192
Mailing Address - Fax:850-659-9565
Practice Address - Street 1:101 GOOD MORNING ST STE 109B
Practice Address - Street 2:
Practice Address - City:PORT ST JOE
Practice Address - State:FL
Practice Address - Zip Code:32456-4765
Practice Address - Country:US
Practice Address - Phone:850-357-8192
Practice Address - Fax:850-659-9565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-18
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty