Provider Demographics
NPI:1063234938
Name:ETIENNE-JEAN, SOPHIA (PMHNP)
Entity type:Individual
Prefix:MRS
First Name:SOPHIA
Middle Name:
Last Name:ETIENNE-JEAN
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10342 MEDICIS PL
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33449-8068
Mailing Address - Country:US
Mailing Address - Phone:786-369-6505
Mailing Address - Fax:
Practice Address - Street 1:1166 E BLUE HERON BLVD
Practice Address - Street 2:
Practice Address - City:RIVIERA BEACH
Practice Address - State:FL
Practice Address - Zip Code:33404-4738
Practice Address - Country:US
Practice Address - Phone:844-497-0788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-30
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL110342452084P0802X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry