Provider Demographics
NPI:1225621808
Name:FLETCHER, LIBBIE DENISE (RDH)
Entity Type:Individual
Prefix:
First Name:LIBBIE
Middle Name:DENISE
Last Name:FLETCHER
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:LIBBIE
Other - Middle Name:DENISE
Other - Last Name:GOODWIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2804 REMINGTON GREEN CIR STE 2
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-1550
Mailing Address - Country:US
Mailing Address - Phone:850-385-4494
Mailing Address - Fax:
Practice Address - Street 1:1249 STRONG RD
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:FL
Practice Address - Zip Code:32351-5248
Practice Address - Country:US
Practice Address - Phone:850-875-9502
Practice Address - Fax:850-627-2786
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-16
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL7761124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL124Q00000XMedicaid
FL7761Medicaid