Healthcare Provider Details

I. General information

NPI: 1497276182
Provider Name (Legal Business Name): ROSA JENELLE JOSEPH DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2017
Last Update Date: 03/31/2022
Certification Date: 03/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 BENMORE DR STE 200
WINTER PARK FL
32792-4111
US

IV. Provider business mailing address

1201 1ST ST S STE 100A
WINTER HAVEN FL
33880-3904
US

V. Phone/Fax

Practice location:
  • Phone: 407-646-7070
  • Fax: 407-646-7747
Mailing address:
  • Phone: 863-280-6080
  • Fax: 863-229-7587

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS16224
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: