Healthcare Provider Details

I. General information

NPI: 1164147393
Provider Name (Legal Business Name): JOSE MARINO-MORALES APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2022
Last Update Date: 09/08/2025
Certification Date: 09/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5615 S FLORIDA AVE STE 111
LAKELAND FL
33813-2714
US

IV. Provider business mailing address

6100 BLUE LAGOON DR STE 365
MIAMI FL
33126-7010
US

V. Phone/Fax

Practice location:
  • Phone: 863-327-0132
  • Fax:
Mailing address:
  • Phone: 786-322-7333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN11022448
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11022448
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: