Provider Demographics
NPI:1629041405
Name:MCSPADDEN, JUANITA TODD (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:JUANITA
Middle Name:TODD
Last Name:MCSPADDEN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:MRS
Other - First Name:JUANITA
Other - Middle Name:
Other - Last Name:BETANCOURT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:217 NE FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32055
Mailing Address - Country:US
Mailing Address - Phone:386-758-1068
Mailing Address - Fax:386-758-2180
Practice Address - Street 1:217 NE FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055
Practice Address - Country:US
Practice Address - Phone:386-758-1068
Practice Address - Fax:386-758-2180
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1372732163W00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL302004500Medicaid