Provider Demographics
NPI:1245461508
Name:HUTTO, CLARENCE MICHAEL (NP)
Entity type:Individual
Prefix:
First Name:CLARENCE
Middle Name:MICHAEL
Last Name:HUTTO
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 MAR WALT DRIVE
Mailing Address - Street 2:IMMEDIATE CARE DEPARTMENT
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6796
Mailing Address - Country:US
Mailing Address - Phone:850-863-8219
Mailing Address - Fax:850-863-8249
Practice Address - Street 1:1005 MAR WALT DRIVE
Practice Address - Street 2:IMMEDIATE CARE DEPARTMENT
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6796
Practice Address - Country:US
Practice Address - Phone:850-863-8219
Practice Address - Fax:850-863-8249
Is Sole Proprietor?:No
Enumeration Date:2009-08-05
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9171115363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010403200Medicaid
FLY0KS7OtherBCBSFL
FLY0KS7OtherBCBSFL