Healthcare Provider Details

I. General information

NPI: 1730623851
Provider Name (Legal Business Name): JESSICA ALEXANDRA FENNELL-THOMAS APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2016
Last Update Date: 02/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1148 E GIBSON ST BLDG B
ARCADIA FL
34266-5011
US

IV. Provider business mailing address

700 8TH AVE W STE 101
PALMETTO FL
34221-4737
US

V. Phone/Fax

Practice location:
  • Phone: 863-494-6222
  • Fax: 863-494-3227
Mailing address:
  • Phone: 941-776-4000
  • Fax: 941-845-4963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN9294156
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: