Provider Demographics
NPI:1538285549
Name:MIDDLETON, DORENDA MELLYN (CRT)
Entity Type:Individual
Prefix:MRS
First Name:DORENDA
Middle Name:MELLYN
Last Name:MIDDLETON
Suffix:
Gender:F
Credentials:CRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1952
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32056-1952
Mailing Address - Country:US
Mailing Address - Phone:386-438-5493
Mailing Address - Fax:386-438-5493
Practice Address - Street 1:547 NE LAKE DR
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-3446
Practice Address - Country:US
Practice Address - Phone:386-438-5493
Practice Address - Fax:386-438-5493
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTT003783227800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes227800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Certified
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL005972000Medicaid