{
"Npi": {
"NPI": "1558074286",
"EntityType": "Individual",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": "Y",
"IsOrgSubpart": null,
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": null,
"LastName": "DORELUS",
"FirstName": "WADVENS",
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": "D4G9H6Y6",
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": "DORELUS",
"OtherFirstName": "WADVENS",
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": "MEDICAL ASSISTANT",
"OtherLastNameTypeCode": "5",
"FirstLineMailingAddress": "421 W 30TH ST",
"SecondLineMailingAddress": "MOBILIZE",
"MailingAddressCityName": "RIVIERA BEACH",
"MailingAddressStateName": "FL",
"MailingAddressPostalCode": "33404",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "561-568-6646",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "421 W 30TH ST",
"SecondLinePracticeLocationAddress": "MOBILIZE",
"PracticeLocationAddressCityName": "RIVIERA BEACH",
"PracticeLocationAddressStateName": "FL",
"PracticeLocationAddressPostalCode": "33404",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "561-568-6646",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "12/27/2022",
"LastUpdateDate": "12/27/2022",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "M",
"Gender": "Male",
"AuthorizedOfficialLastName": null,
"AuthorizedOfficialFirstName": null,
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": null,
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": null,
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "172A00000X",
"TaxonomyName": "Driver",
"LicenseNumber": "D4G9H6Y6",
"LicenseNumberStateCode": "FL",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "174400000X",
"TaxonomyName": "Specialist",
"LicenseNumber": "D4G9H6Y6",
"LicenseNumberStateCode": "FL",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "207PH0002X",
"TaxonomyName": "Hospice and Palliative Medicine (Emergency Medicine) Physician",
"LicenseNumber": "D4G9H6Y6",
"LicenseNumberStateCode": "FL",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "372600000X",
"TaxonomyName": "Adult Companion",
"LicenseNumber": "D4G9H6Y6",
"LicenseNumberStateCode": "FL",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "3747P1801X",
"TaxonomyName": "Personal Care Attendant",
"LicenseNumber": "D4G9H6Y6",
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "374U00000X",
"TaxonomyName": "Home Health Aide",
"LicenseNumber": "D4G9H6Y6",
"LicenseNumberStateCode": "FL",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "376K00000X",
"TaxonomyName": "Nurse's Aide",
"LicenseNumber": "D4G9H6Y6",
"LicenseNumberStateCode": "FL",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "405300000X",
"TaxonomyName": "Prevention Professional",
"LicenseNumber": "D4G9H6Y6",
"LicenseNumberStateCode": "FL",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "156F00000X",
"TaxonomyName": "Technician/Technologist",
"LicenseNumber": "D4G9H6Y6",
"LicenseNumberStateCode": "FL",
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": null
}
}