Healthcare Provider Details

I. General information

NPI: 1467397091
Provider Name (Legal Business Name): KENNY MIGUEL MUNIZ DOMENA APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2026
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

335 N MAGNOLIA AVE APT 413
ORLANDO FL
32801-1793
US

IV. Provider business mailing address

335 N MAGNOLIA AVE APT 413
ORLANDO FL
32801-1793
US

V. Phone/Fax

Practice location:
  • Phone: 347-439-5686
  • Fax:
Mailing address:
  • Phone: 347-439-5686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11045487
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: