Provider Demographics
NPI:1467042366
Name:FIEULLETEAU, JODYON (PROSTHETIC SPECIALIS)
Entity type:Individual
Prefix:
First Name:JODYON
Middle Name:
Last Name:FIEULLETEAU
Suffix:
Gender:F
Credentials:PROSTHETIC SPECIALIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2513 LOBELIA DR
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-2680
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2513 LOBELIA DR
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-2680
Practice Address - Country:US
Practice Address - Phone:973-901-5860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-25
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1744P3200X, 335E00000X
332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
No335E00000XSuppliersProsthetic/Orthotic Supplier