Healthcare Provider Details

I. General information

NPI: 1083966717
Provider Name (Legal Business Name): JONELLE MORICIA RIVAS-GIBSON ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2012
Last Update Date: 12/21/2022
Certification Date: 11/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 N STATE ROAD 7 STE 200
LAUDERHILL FL
33313-5853
US

IV. Provider business mailing address

5607 NW 27TH AVE SUITE 1
MIAMI FL
33142-2826
US

V. Phone/Fax

Practice location:
  • Phone: 954-900-9804
  • Fax:
Mailing address:
  • Phone: 305-805-1700
  • Fax: 305-805-1715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberARNP9266389
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code364SP0813X
TaxonomyGeropsychiatric Psychiatric/Mental Health Clinical Nurse Specialist
License NumberAPRN9266389
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN9266389
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: