Provider Demographics
NPI:1700252046
Name:NETTLETON, MEGAN
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:NETTLETON
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 1:3791 28TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33713-3447
Mailing Address - Country:US
Mailing Address - Phone:770-289-1348
Mailing Address - Fax:
Practice Address - Street 1:111 2ND AVE NE STE 900
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-3434
Practice Address - Country:US
Practice Address - Phone:727-452-1710
Practice Address - Fax:727-213-6233
Is Sole Proprietor?:No
Enumeration Date:2015-08-20
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ7209235Z00000X
FLSA14795235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015537200Medicaid