MEDICARE: MR. JACK FACUNDUS ARNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	ARNP2824142	FL
2	363LF0000X	Family Nurse Practitioner	090740-23	NH
3	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	APRN2824142	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	F0416038	OTHER	FL	AMERICAN ACADEMY OF NURSE PRACTITIONERS CERTIFICATION PROGRAM
2	ARNP2824142	OTHER	FL	STATE OF FLORIDA ARNP LICENSE

General Provider Information

NPI Number	:	1376092809
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JACK FACUNDUS ARNP

Provider Business Mailing Address
First Line	:	5151 ADANSON ST
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32804-1317
Country	:	US
Telephone Number	:	407-875-3700
Fax Number	:

Provider Business Practice Location Address
First Line	:	651 W WARREN AVE STE 100
Second Line	:
City	:	LONGWOOD
State	:	FL
Zip	:	32750-4036
Country	:	US
Telephone Number	:	321-999-9617
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/26/2016
Last Update Date	:	06/14/2024

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