Provider Demographics
NPI:1710066576
Name:DANTZLER, VICKY E (RN)
Entity Type:Individual
Prefix:
First Name:VICKY
Middle Name:E
Last Name:DANTZLER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 RALPH LONG RD
Mailing Address - Street 2:
Mailing Address - City:DEFUNIAK SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32433-0830
Mailing Address - Country:US
Mailing Address - Phone:850-533-6018
Mailing Address - Fax:
Practice Address - Street 1:324 RALPH LONG RD
Practice Address - Street 2:
Practice Address - City:DEFUNIAK SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32433-0830
Practice Address - Country:US
Practice Address - Phone:850-533-6018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN3378712163W00000X, 222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015798500Medicaid