Provider Demographics
NPI:1306574181
Name:PERRELL, WALTER HANEY III (FNP-C)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:HANEY
Last Name:PERRELL
Suffix:III
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6394 W CONSTITUTION LN
Mailing Address - Street 2:
Mailing Address - City:HOMOSASSA
Mailing Address - State:FL
Mailing Address - Zip Code:34448-1653
Mailing Address - Country:US
Mailing Address - Phone:352-613-6873
Mailing Address - Fax:
Practice Address - Street 1:502 W HIGHLAND BLVD
Practice Address - Street 2:
Practice Address - City:INVERNESS
Practice Address - State:FL
Practice Address - Zip Code:34452-4720
Practice Address - Country:US
Practice Address - Phone:352-726-1551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-10
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11021321363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner