Basic Information
| Provider Information | |||||||||
| NPI: | 1659465755 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SUMMERS | ||||||||
| FirstName: | MARLENE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6400 W NEWBERRY RD | ||||||||
| Address2: | STE 207 | ||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326056600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523712011 | ||||||||
| FaxNumber: | 3523843611 | ||||||||
| Practice Location | |||||||||
| Address1: | 449 SE BAYA DRIVE | ||||||||
| Address2: | |||||||||
| City: | LAKE CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3867550500 | ||||||||
| FaxNumber: | 3867559217 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 10/12/2016 | ||||||||
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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 | 363LX0001X | 1370482 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 240386 | 01 | FL | AVMED | OTHER | Y9008 | 01 | FL | BCBS PROVIDER NUMBER | OTHER | 340059000 | 05 | FL | MEDICAID |