Basic Information
| Provider Information | |||||||||
| NPI: | 1477069516 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUXTABLE | ||||||||
| FirstName: | DEBORAHLIN | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6360 TECHSTER BLVD STE 1 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339664805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392232751 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2830 WINKLER AVE STE 207 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339169301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392154600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2017 | ||||||||
| LastUpdateDate: | 06/05/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | APRN9291074 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363LP0808X | APRN9291074 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 025099000 | 05 | FL | MEDICAID |