Healthcare Provider Details

I. General information

NPI: 1295122786
Provider Name (Legal Business Name): JAYAR BANEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2015
Last Update Date: 04/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17240 CORTEZ BLVD
BROOKSVILLE FL
34601-8921
US

IV. Provider business mailing address

3768 103RD AVE N
CLEARWATER FL
33762-5476
US

V. Phone/Fax

Practice location:
  • Phone: 352-796-5111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License NumberARNP9246017
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: