=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497100283
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MADELYN MITJANS FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/28/2016
-----------------------------------------------------
Last Update Date | 04/28/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3752 W 12TH AVE
-----------------------------------------------------
City | HIALEAH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33012-4126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-231-7599
-----------------------------------------------------
Fax | 305-231-7598
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 437 SANTANDER AVE APT A
-----------------------------------------------------
City | CORAL GABLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33134-6538
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-231-7599
-----------------------------------------------------
Fax | 305-231-7599
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | ARNP9359035
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------