Provider Demographics
NPI:1518784040
Name:LANGFORD, MARISSA AMBER
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:AMBER
Last Name:LANGFORD
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:PO BOX 100294
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32610-0294
Mailing Address - Country:US
Mailing Address - Phone:352-273-7584
Mailing Address - Fax:352-392-3498
Practice Address - Street 1:1549 GALE LEMERAND DR
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3008
Practice Address - Country:US
Practice Address - Phone:352-265-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-25
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11034423363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL124417000Medicaid