Provider Demographics
NPI:1306192216
Name:EMERALD WATERS MEDICAL CLINIC LLC
Entity Type:Organization
Organization Name:EMERALD WATERS MEDICAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:MS
Authorized Official - First Name:MAURICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:STANTON
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:850-582-6059
Mailing Address - Street 1:1005 COLLEGE BLVD W
Mailing Address - Street 2:SUITE B
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-1060
Mailing Address - Country:US
Mailing Address - Phone:850-279-6815
Mailing Address - Fax:850-279-6817
Practice Address - Street 1:1005 COLLEGE BLVD W
Practice Address - Street 2:SUITE B
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-1060
Practice Address - Country:US
Practice Address - Phone:850-279-6815
Practice Address - Fax:850-279-6817
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-28
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363L00000X, 363LP2300X
FLARNP3114742363LA2200X, 363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLQ54432Medicare UPIN