Provider Demographics
NPI:1417931585
Name:PRATT, JANE A
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:A
Last Name:PRATT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 CREWILLA DR NW
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548-3947
Mailing Address - Country:US
Mailing Address - Phone:850-581-7700
Mailing Address - Fax:850-244-5342
Practice Address - Street 1:219 CREWILLA DR NW
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548-3947
Practice Address - Country:US
Practice Address - Phone:850-581-7700
Practice Address - Fax:850-244-5342
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLR9474OtherBCBS PROVIDER NUMBER
4925550001Medicare NSC