Healthcare Provider Details

I. General information

NPI: 1215204771
Provider Name (Legal Business Name): JENNIFER ANN VIGNOLA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2011
Last Update Date: 11/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4011 W FLAGLER ST SUITE 202
MIAMI FL
33134-1643
US

IV. Provider business mailing address

4011 W FLAGLER ST SUITE 202
MIAMI FL
33134-1643
US

V. Phone/Fax

Practice location:
  • Phone: 305-541-3030
  • Fax: 305-541-0333
Mailing address:
  • Phone: 305-541-3030
  • Fax: 305-541-0333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN-19540
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: