Provider Demographics
NPI:1124761093
Name:HAVLAT, RATTANAVALEE JANSOD (APRN)
Entity type:Individual
Prefix:
First Name:RATTANAVALEE
Middle Name:JANSOD
Last Name:HAVLAT
Suffix:
Gender:
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1118 HOSPITAL RD
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6742
Mailing Address - Country:US
Mailing Address - Phone:850-862-3415
Mailing Address - Fax:
Practice Address - Street 1:1118 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6742
Practice Address - Country:US
Practice Address - Phone:850-862-3415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-18
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11018735363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health