Healthcare Provider Details

I. General information

NPI: 1083967806
Provider Name (Legal Business Name): JOLENE KEIKO GORANOVIC AA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2012
Last Update Date: 02/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1304 OAK ST
MELBOURNE FL
32901-3111
US

IV. Provider business mailing address

PO BOX 2400
MELBOURNE FL
32902-2400
US

V. Phone/Fax

Practice location:
  • Phone: 321-723-4723
  • Fax:
Mailing address:
  • Phone: 321-255-9671
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License NumberAA 132
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: