Provider Demographics
NPI:1003331133
Name:MATTIS, JONELLE A (FNP-BC)
Entity Type:Individual
Prefix:
First Name:JONELLE
Middle Name:A
Last Name:MATTIS
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4430 NW 34TH ST
Mailing Address - Street 2:
Mailing Address - City:LAUDERDALE LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33319-5702
Mailing Address - Country:US
Mailing Address - Phone:754-422-2484
Mailing Address - Fax:
Practice Address - Street 1:8201 PETERS RD STE 1000
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-3266
Practice Address - Country:US
Practice Address - Phone:877-964-9378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-10
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9312189363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty