Provider Demographics
NPI:1245648542
Name:HUCKABY, KATIE
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:HUCKABY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 MARINER WAY
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32550-6931
Mailing Address - Country:US
Mailing Address - Phone:270-779-0143
Mailing Address - Fax:
Practice Address - Street 1:4164 W COUNTY HIGHWAY 30A
Practice Address - Street 2:
Practice Address - City:SANTA ROSA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32459-4336
Practice Address - Country:US
Practice Address - Phone:850-622-2313
Practice Address - Fax:850-622-2718
Is Sole Proprietor?:No
Enumeration Date:2014-07-30
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3008797363LF0000X
FL9490444363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily