Healthcare Provider Details

I. General information

NPI: 1700396801
Provider Name (Legal Business Name): CARL IVAN DENIS PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2017
Last Update Date: 04/20/2020
Certification Date: 04/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 NE 125TH ST
NORTH MIAMI FL
33161-5019
US

IV. Provider business mailing address

1150 NE 125TH ST
NORTH MIAMI FL
33161-5019
US

V. Phone/Fax

Practice location:
  • Phone: 305-403-0654
  • Fax:
Mailing address:
  • Phone: 305-403-0654
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number9337095
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: