Provider Demographics
NPI:1497394738
Name:THAXTER, DENISE
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:THAXTER
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 1:3262 PEBBLEBROOKE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33810-1305
Mailing Address - Country:US
Mailing Address - Phone:863-853-6325
Mailing Address - Fax:
Practice Address - Street 1:3262 PEBBLEBROOKE BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33810-1305
Practice Address - Country:US
Practice Address - Phone:863-853-6325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-03
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11004251363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily