Healthcare Provider Details

I. General information

NPI: 1396478897
Provider Name (Legal Business Name): MAKENSON GEFFRARD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2022
Last Update Date: 07/03/2022
Certification Date: 06/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4118 SW UTTERBACK ST
PORT SAINT LUCIE FL
34953-6100
US

IV. Provider business mailing address

4118 SW UTTERBACK ST
PORT SAINT LUCIE FL
34953-6100
US

V. Phone/Fax

Practice location:
  • Phone: 772-607-0492
  • Fax:
Mailing address:
  • Phone: 772-607-0492
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number11020573
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: