Provider Demographics
NPI:1538146824
Name:MERRITT, THEATA JEANNE (NURSE PRACTITIONER)
Entity type:Individual
Prefix:DR
First Name:THEATA
Middle Name:JEANNE
Last Name:MERRITT
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4902 OAKSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33625-6615
Mailing Address - Country:US
Mailing Address - Phone:813-963-1779
Mailing Address - Fax:813-903-7831
Practice Address - Street 1:4902 OAKSHIRE DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33625-6615
Practice Address - Country:US
Practice Address - Phone:813-963-1779
Practice Address - Fax:813-903-7831
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL416522363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3022552 00Medicaid
FLS71231Medicare UPIN
FL3022552 00Medicaid