Provider Demographics
NPI:1376545608
Name:HATHAWAY, VALERIE LYNN (ARNP)
Entity Type:Individual
Prefix:
First Name:VALERIE
Middle Name:LYNN
Last Name:HATHAWAY
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3014 TAMIAMI TRL
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-4358
Mailing Address - Country:US
Mailing Address - Phone:941-625-7775
Mailing Address - Fax:941-625-2226
Practice Address - Street 1:5952 CLARK CENTER AVE
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34238-2715
Practice Address - Country:US
Practice Address - Phone:941-924-9955
Practice Address - Fax:941-924-5165
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1096022363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL307342400Medicaid
FLU6726UMedicare UPIN
FL307342400Medicaid