Healthcare Provider Details

I. General information

NPI: 1639848419
Provider Name (Legal Business Name): JUAN C PONCE APRN, PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2021
Last Update Date: 04/29/2024
Certification Date: 04/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8323 NW 12TH ST STE 108
DORAL FL
33126-1839
US

IV. Provider business mailing address

3501 DEL PRADO BLVD S STE 303
CAPE CORAL FL
33904-7222
US

V. Phone/Fax

Practice location:
  • Phone: 305-400-8511
  • Fax: 305-392-0184
Mailing address:
  • Phone: 239-317-0265
  • Fax: 239-673-7681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberAPRN11012428
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11012428
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN11012428
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: