Healthcare Provider Details

I. General information

NPI: 1033454731
Provider Name (Legal Business Name): JENNIFER L SIEGEL ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2012
Last Update Date: 07/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 S LAWRENCE BLVD SUITE A
KEYSTONE HEIGHTS FL
32656-9222
US

IV. Provider business mailing address

445 S LAWRENCE BLVD SUITE A
KEYSTONE HEIGHTS FL
32656-9222
US

V. Phone/Fax

Practice location:
  • Phone: 352-562-7927
  • Fax: 770-319-1019
Mailing address:
  • Phone: 352-562-7927
  • Fax: 770-319-1019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number9204294
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: