Provider Demographics
NPI:1487439394
Name:360 BLUE FAMILY MEDICAL LLC
Entity type:Organization
Organization Name:360 BLUE FAMILY MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EMPLOYEE
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLUE
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, APRN, FNP-BC,
Authorized Official - Phone:850-319-7345
Mailing Address - Street 1:949 JENKS AVE STE 6
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32401-2584
Mailing Address - Country:US
Mailing Address - Phone:904-853-0809
Mailing Address - Fax:
Practice Address - Street 1:949 JENKS AVE STE 6
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-2584
Practice Address - Country:US
Practice Address - Phone:904-853-0809
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-29
Last Update Date:2023-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty