Healthcare Provider Details

I. General information

NPI: 1821462425
Provider Name (Legal Business Name): JEMMA SMALL PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2015
Last Update Date: 05/25/2021
Certification Date: 05/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2884 MOONSTONE BND
KISSIMMEE FL
34758-2543
US

IV. Provider business mailing address

2884 MOONSTONE BND
KISSIMMEE FL
34758-2543
US

V. Phone/Fax

Practice location:
  • Phone: 407-922-4282
  • Fax:
Mailing address:
  • Phone: 407-922-4282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP2697802
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2697802
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: