Provider Demographics
NPI:1245747385
Name:VAN VLIET, MARY ELIZABETH (APRN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:VAN VLIET
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2617 MITCHAM DR STE 102
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-5479
Mailing Address - Country:US
Mailing Address - Phone:850-878-1171
Mailing Address - Fax:850-942-1291
Practice Address - Street 1:2617 MITCHAM DR STE 102
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-5479
Practice Address - Country:US
Practice Address - Phone:850-878-1171
Practice Address - Fax:850-942-1291
Is Sole Proprietor?:No
Enumeration Date:2018-01-10
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9335972363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL100847000Medicaid
FL060754100Medicaid