Provider Demographics
NPI:1013360395
Name:JEAN-NOEL, DERLY
Entity Type:Individual
Prefix:MRS
First Name:DERLY
Middle Name:
Last Name:JEAN-NOEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3380 WILDERNESS TRL
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34746-2926
Mailing Address - Country:US
Mailing Address - Phone:407-973-9432
Mailing Address - Fax:
Practice Address - Street 1:3380 WILDERNESS TRL
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34746-2926
Practice Address - Country:US
Practice Address - Phone:407-973-9432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-21
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 94731207Q00000X
FL4450282N00000X
302F00000X
FLAG0316099363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No302F00000XManaged Care OrganizationsExclusive Provider Organization
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner