=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235423120
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JEANNE-ELYSE CEDENO M.D., P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2011
-----------------------------------------------------
Last Update Date | 06/21/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10041 PINES BLVD STE A
-----------------------------------------------------
City | PEMBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33024-6170
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 754-273-6278
-----------------------------------------------------
Fax | 954-374-6954
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10041 PINES BLVD STE A
-----------------------------------------------------
City | PEMBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33024-6170
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 754-273-6278
-----------------------------------------------------
Fax | 954-374-6954
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, PHYSICIAN
-----------------------------------------------------
Name | DR. JEANNE-ELYSE GRAY CEDENO
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 754-273-6278
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | ME 106978
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------