Healthcare Provider Details

I. General information

NPI: 1881332609
Provider Name (Legal Business Name): LISE JEAN JACQUES RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2022
Last Update Date: 05/23/2022
Certification Date: 05/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 NE 130TH ST
NORTH MIAMI FL
33161-7527
US

IV. Provider business mailing address

765 WHIPPOORWILL ROW
WEST PALM BEACH FL
33411-5231
US

V. Phone/Fax

Practice location:
  • Phone: 786-241-1274
  • Fax:
Mailing address:
  • Phone: 786-241-1274
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number9413465
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: