Provider Demographics
NPI:1306106844
Name:AVILA, JESSICA (ARNP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:AVILA
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 CORPORATE WAY
Mailing Address - Street 2:DOOR D
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-3925
Mailing Address - Country:US
Mailing Address - Phone:954-276-5685
Mailing Address - Fax:
Practice Address - Street 1:603 N FLAMINGO ROAD
Practice Address - Street 2:STE 157
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33028
Practice Address - Country:US
Practice Address - Phone:954-265-4325
Practice Address - Fax:954-438-5191
Is Sole Proprietor?:No
Enumeration Date:2012-05-17
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 9250148363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017950300Medicaid
FL9208882OtherAETNA
FLGK655ZMedicare PIN