Provider Demographics
NPI:1619411279
Name:BAKER, BRECK (PMHNP -BC)
Entity Type:Individual
Prefix:DR
First Name:BRECK
Middle Name:
Last Name:BAKER
Suffix:
Gender:F
Credentials:PMHNP -BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 SAN SEBASTIAN VW STE 2102
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-8695
Mailing Address - Country:US
Mailing Address - Phone:800-539-4228
Mailing Address - Fax:904-209-6288
Practice Address - Street 1:200 SAN SEBASTIAN VW STE 2102
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-8695
Practice Address - Country:US
Practice Address - Phone:800-539-4228
Practice Address - Fax:904-209-6288
Is Sole Proprietor?:No
Enumeration Date:2016-12-15
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN 256580363LF0000X
FLAPRN11001264363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily