Provider Demographics
NPI:1063519148
Name:DIJEROME, LAURA ANN (RN, CNP)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:ANN
Last Name:DIJEROME
Suffix:
Gender:F
Credentials:RN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 WOODLAND AVE
Mailing Address - Street 2:
Mailing Address - City:COCOA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32931-2854
Mailing Address - Country:US
Mailing Address - Phone:321-799-2840
Mailing Address - Fax:
Practice Address - Street 1:80 WOODLAND AVE
Practice Address - Street 2:
Practice Address - City:COCOA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32931-2854
Practice Address - Country:US
Practice Address - Phone:321-799-2840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2015-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9341204363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP322604Medicaid
OHPO8123Medicare ID - Type Unspecified