Provider Demographics
NPI:1477960888
Name:DEBAULT, DEETTA L (ARNP)
Entity Type:Individual
Prefix:
First Name:DEETTA
Middle Name:L
Last Name:DEBAULT
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2675 WINKLER AVE
Mailing Address - Street 2:FL 2
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:239-278-3600
Mailing Address - Fax:239-278-3857
Practice Address - Street 1:2232 GRAND AVE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-3717
Practice Address - Country:US
Practice Address - Phone:239-344-2330
Practice Address - Fax:239-332-4701
Is Sole Proprietor?:No
Enumeration Date:2014-07-17
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9277422363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012471200Medicaid