Provider Demographics
NPI:1447966809
Name:TEZAK, EMILY ANNE
Entity type:Individual
Prefix:MISS
First Name:EMILY
Middle Name:ANNE
Last Name:TEZAK
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 1:1014 LONG AVE
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT JOE
Mailing Address - State:FL
Mailing Address - Zip Code:32456-2012
Mailing Address - Country:US
Mailing Address - Phone:219-728-9540
Mailing Address - Fax:
Practice Address - Street 1:202 W HIGHWAY 98
Practice Address - Street 2:
Practice Address - City:PORT ST JOE
Practice Address - State:FL
Practice Address - Zip Code:32456-1303
Practice Address - Country:US
Practice Address - Phone:850-227-9220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-27
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11024016363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner