Provider Demographics
NPI:1609407428
Name:RICHTER, MALISSA ANN (APRN)
Entity Type:Individual
Prefix:
First Name:MALISSA
Middle Name:ANN
Last Name:RICHTER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MALISSA
Other - Middle Name:ANN
Other - Last Name:DETWILER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5978 POWERS AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32217-2210
Mailing Address - Country:US
Mailing Address - Phone:904-399-2525
Mailing Address - Fax:
Practice Address - Street 1:5978 POWERS AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-2210
Practice Address - Country:US
Practice Address - Phone:904-339-2525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-30
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11005262363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily