Provider Demographics
NPI:1144570862
Name:DEBOLT, PETRA (ARNP)
Entity Type:Individual
Prefix:
First Name:PETRA
Middle Name:
Last Name:DEBOLT
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:PETRA
Other - Middle Name:
Other - Last Name:DUGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-424-1449
Mailing Address - Fax:239-424-1421
Practice Address - Street 1:3511 MARTIN LUTHER KING BLVD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33916-4651
Practice Address - Country:US
Practice Address - Phone:239-343-4910
Practice Address - Fax:239-343-4911
Is Sole Proprietor?:No
Enumeration Date:2012-09-11
Last Update Date:2015-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2944422363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008624400Medicaid
FL008624400Medicaid