Healthcare Provider Details

I. General information

NPI: 1750166856
Provider Name (Legal Business Name): JENNIFET GRANDA ALFONSO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2023
Last Update Date: 04/02/2025
Certification Date: 04/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10521 SW 166TH ST
MIAMI FL
33157-3065
US

IV. Provider business mailing address

10521 SW 166TH ST
MIAMI FL
33157-3065
US

V. Phone/Fax

Practice location:
  • Phone: 239-233-1248
  • Fax:
Mailing address:
  • Phone: 239-233-1248
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberBACB842112
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: