Provider Demographics
NPI:1245800226
Name:STATLER, DESIREE NICOLII (APRN)
Entity Type:Individual
Prefix:
First Name:DESIREE
Middle Name:NICOLII
Last Name:STATLER
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 1:2315 W JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32505-7552
Mailing Address - Country:US
Mailing Address - Phone:850-436-4630
Mailing Address - Fax:
Practice Address - Street 1:2315 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32505-7552
Practice Address - Country:US
Practice Address - Phone:850-436-4630
Practice Address - Fax:850-436-2095
Is Sole Proprietor?:No
Enumeration Date:2021-06-30
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11013529363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner