Healthcare Provider Details

I. General information

NPI: 1659736767
Provider Name (Legal Business Name): HARRY JEAN FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2015
Last Update Date: 03/04/2022
Certification Date: 03/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 HEALTH PARK DR
MOORE HAVEN FL
33471-6206
US

IV. Provider business mailing address

107 JFK DR STE B
ATLANTIS FL
33462-1153
US

V. Phone/Fax

Practice location:
  • Phone: 863-946-0405
  • Fax:
Mailing address:
  • Phone: 561-966-7717
  • Fax: 888-316-2198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP 9385232
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: