Provider Demographics
NPI:1356886196
Name:FRAZIER, DESHALA (APRN)
Entity type:Individual
Prefix:
First Name:DESHALA
Middle Name:
Last Name:FRAZIER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2804 REMINGTON GREEN CIR STE 2
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-1550
Mailing Address - Country:US
Mailing Address - Phone:850-385-4494
Mailing Address - Fax:
Practice Address - Street 1:235 SW DADE ST STE A
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:FL
Practice Address - Zip Code:32340-2363
Practice Address - Country:US
Practice Address - Phone:850-973-1402
Practice Address - Fax:850-973-1450
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-04
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9303538163WH0200X
FLAPRN11028468363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL120987400Medicaid