Healthcare Provider Details

I. General information

NPI: 1851908859
Provider Name (Legal Business Name): DEJA DUCLOS APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2020
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11557 VIA LUCERNA CIR
WINDERMERE FL
34786-6077
US

IV. Provider business mailing address

11557 VIA LUCERNA CIR
WINDERMERE FL
34786-6077
US

V. Phone/Fax

Practice location:
  • Phone: 407-692-2622
  • Fax:
Mailing address:
  • Phone: 407-692-2622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11037065
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: