Provider Demographics
NPI:1730673815
Name:DENECKE, MARLA GAIL (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:MARLA
Middle Name:GAIL
Last Name:DENECKE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1233 HUNTINGTON RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:LYNN HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:32444-3190
Mailing Address - Country:US
Mailing Address - Phone:850-258-4032
Mailing Address - Fax:
Practice Address - Street 1:2704 THOMAS DR
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32408-6247
Practice Address - Country:US
Practice Address - Phone:850-236-8655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-21
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9247175363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner