Provider Demographics
NPI:1255708681
Name:DEDEAUX, MAILANDE (PA)
Entity type:Individual
Prefix:
First Name:MAILANDE
Middle Name:
Last Name:DEDEAUX
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MAILANDE
Other - Middle Name:
Other - Last Name:PARKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 280
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32562-0280
Mailing Address - Country:US
Mailing Address - Phone:850-932-5055
Mailing Address - Fax:850-932-1404
Practice Address - Street 1:400 GULF BREEZE PKWY
Practice Address - Street 2:SUITE 300
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32561-4458
Practice Address - Country:US
Practice Address - Phone:850-932-5055
Practice Address - Fax:850-932-1404
Is Sole Proprietor?:No
Enumeration Date:2015-09-02
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108878363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLJL0YBOtherBLUE CROSS BLUE SHIELD