Healthcare Provider Details

I. General information

NPI: 1871912071
Provider Name (Legal Business Name): JONELLE RIVAS GIBSON ARNP PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2014
Last Update Date: 04/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 S FEDERAL HWY STE 101
DANIA BEACH FL
33004-4005
US

IV. Provider business mailing address

250 S FEDERAL HWY STE 101
DANIA BEACH FL
33004-4005
US

V. Phone/Fax

Practice location:
  • Phone: 954-900-9804
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9266389
License Number StateFL

VIII. Authorized Official

Name: JONELLE RIVAS GIBSON
Title or Position: OWNER
Credential:
Phone: 954-900-9804