Healthcare Provider Details

I. General information

NPI: 1699697896
Provider Name (Legal Business Name): JESSICA FANELLI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2026
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 PINE RIDGE TER
DAVIE FL
33325-1272
US

IV. Provider business mailing address

650 PINE RIDGE TER
DAVIE FL
33325-1272
US

V. Phone/Fax

Practice location:
  • Phone: 954-260-5780
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11049572
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: