Provider Demographics
NPI:1801371430
Name:REEVES, MARTHA KELLY WALDREP (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:KELLY WALDREP
Last Name:REEVES
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 1:1449 NW LITTLE CAT RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:FL
Mailing Address - Zip Code:32340-4260
Mailing Address - Country:US
Mailing Address - Phone:904-537-2298
Mailing Address - Fax:
Practice Address - Street 1:486 SW RUTLEDGE ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:FL
Practice Address - Zip Code:32340-1978
Practice Address - Country:US
Practice Address - Phone:850-973-8851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-29
Last Update Date:2018-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9280528363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLARNP9280528OtherARNP LICENSE