Healthcare Provider Details

I. General information

NPI: 1538024955
Provider Name (Legal Business Name): MARVALEE DIANNE HARRIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2025
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5743 NW ESKIMO CIR
PORT SAINT LUCIE FL
34986-4155
US

IV. Provider business mailing address

5743 NW ESKIMO CIR
PORT SAINT LUCIE FL
34986-4155
US

V. Phone/Fax

Practice location:
  • Phone: 772-267-1819
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11044114
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: