Provider Demographics
NPI:1033889175
Name:JIVIDEN, DANIELLE NICOLE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:DANIELLE
Middle Name:NICOLE
Last Name:JIVIDEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-2052
Mailing Address - Fax:239-343-5848
Practice Address - Street 1:9981 S HEALTHPARK DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-3618
Practice Address - Country:US
Practice Address - Phone:239-343-2052
Practice Address - Fax:239-343-5848
Is Sole Proprietor?:No
Enumeration Date:2021-09-20
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
FLPA9115006363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL114926700Medicaid