MEDICARE: MAKENSON GEFFRARD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	11020573	FL

General Provider Information

NPI Number	:	1396478897
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAKENSON GEFFRARD

Provider Business Mailing Address
First Line	:	4118 SW UTTERBACK ST
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34953-6100
Country	:	US
Telephone Number	:	772-607-0492
Fax Number	:

Provider Business Practice Location Address
First Line	:	4118 SW UTTERBACK ST
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34953-6100
Country	:	US
Telephone Number	:	772-607-0492
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/03/2022
Last Update Date	:	07/03/2022

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Directions to “ MAKENSON GEFFRARD ” Practice Location

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