Provider Demographics
NPI:1235865403
Name:SCULLY, JARRETT (APRN)
Entity Type:Individual
Prefix:
First Name:JARRETT
Middle Name:
Last Name:SCULLY
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 MARY ESTHER BLVD
Mailing Address - Street 2:
Mailing Address - City:MARY ESTHER
Mailing Address - State:FL
Mailing Address - Zip Code:32569-1967
Mailing Address - Country:US
Mailing Address - Phone:850-776-3874
Mailing Address - Fax:
Practice Address - Street 1:71 MARY ESTHER BLVD
Practice Address - Street 2:
Practice Address - City:MARY ESTHER
Practice Address - State:FL
Practice Address - Zip Code:32569-1967
Practice Address - Country:US
Practice Address - Phone:850-776-3874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-28
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11021089363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily