Healthcare Provider Details

I. General information

NPI: 1891609517
Provider Name (Legal Business Name): MRS. SANDRA JEANNIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2026
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2513 33RD ST W # NA
LEHIGH ACRES FL
33971-0713
US

IV. Provider business mailing address

2513 33RD ST W # NA
LEHIGH ACRES FL
33971-0713
US

V. Phone/Fax

Practice location:
  • Phone: 239-738-9330
  • Fax:
Mailing address:
  • Phone: 239-738-9330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number11050134
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: