Provider Demographics
NPI:1083136808
Name:JEAN, VENECIA LASALLE
Entity Type:Individual
Prefix:
First Name:VENECIA
Middle Name:LASALLE
Last Name:JEAN
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:VENECIA
Other - Middle Name:LASALLE
Other - Last Name:JEAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRANIAL PROTHESIS
Mailing Address - Street 1:435 NE 171ST TER
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33162-3914
Mailing Address - Country:US
Mailing Address - Phone:908-368-1156
Mailing Address - Fax:
Practice Address - Street 1:6304 NW 14TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33147-8008
Practice Address - Country:US
Practice Address - Phone:908-368-1156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-13
Last Update Date:2017-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist