Healthcare Provider Details

I. General information

NPI: 1023967973
Provider Name (Legal Business Name): GRACIE LATRICE JENKINS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2026
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3605 LIGHT PORT WAY
KISSIMMEE FL
34746-1842
US

IV. Provider business mailing address

3605 LIGHT PORT WAY
KISSIMMEE FL
34746-1842
US

V. Phone/Fax

Practice location:
  • Phone: 689-239-9633
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11045076
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberAPRN11045076
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: