1174810659 NPI number — JEZEL E ROSA APRN

Table of content: JEZEL E ROSA APRN (NPI 1174810659)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174810659 NPI number — JEZEL E ROSA APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROSA
Provider First Name:
JEZEL
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174810659
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/07/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 510591
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KEY COLONY BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33051-0591
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-393-9466
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 W OCEAN DR # 591
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KEY COLONY BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33051-2000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
786-751-2082
Provider Business Practice Location Address Fax Number:
786-590-1944
Provider Enumeration Date:
07/05/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163W00000X , with the licence number:  9386197 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X , with the licence number: APRN11013721 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: RN 9386197 . This is a "RN LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: PMHNP-BC2021032994 . This is a "ANCC" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: APRN11013721 . This is a "FLORIDA DEPARTMENT OF HEALTH" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 111081200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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