Healthcare Provider Details

I. General information

NPI: 1417199589
Provider Name (Legal Business Name): JENNIFER DEMICHELE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2009
Last Update Date: 11/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9732 MOUNT LOMPOC CT
LAS VEGAS NV
89178-7511
US

IV. Provider business mailing address

1500 CONCORD TER
SUNRISE FL
33323-2815
US

V. Phone/Fax

Practice location:
  • Phone: 203-801-8075
  • Fax: 585-442-6580
Mailing address:
  • Phone: 800-243-3839
  • Fax: 954-851-1837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number16249
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: