Healthcare Provider Details

I. General information

NPI: 1366144776
Provider Name (Legal Business Name): JANDY RODRIGUEZ SR. AGACNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2023
Last Update Date: 03/20/2023
Certification Date: 03/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 NW 170TH ST STE 301
NORTH MIAMI BEACH FL
33169-5511
US

IV. Provider business mailing address

100 NW 170TH ST STE 301
NORTH MIAMI BEACH FL
33169-5511
US

V. Phone/Fax

Practice location:
  • Phone: 305-651-3038
  • Fax: 305-655-1153
Mailing address:
  • Phone: 305-651-3038
  • Fax: 305-655-1153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number11025247
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: