Provider Demographics
NPI:1548592645
Name:MADDOX, NANETTE KAY
Entity Type:Individual
Prefix:
First Name:NANETTE
Middle Name:KAY
Last Name:MADDOX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NANETTE
Other - Middle Name:KAY
Other - Last Name:BUIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:424 W JAMES LEE BLVD
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-2638
Mailing Address - Country:US
Mailing Address - Phone:850-689-2260
Mailing Address - Fax:850-398-6211
Practice Address - Street 1:424 W JAMES LEE BLVD
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-2638
Practice Address - Country:US
Practice Address - Phone:850-689-2260
Practice Address - Fax:850-398-6211
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-01
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLE0953246Z00000X
FLFS864804247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
No246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other