Provider Demographics
NPI:1083315634
Name:TASE CORRIA, JENNY
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:
Last Name:TASE CORRIA
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 1:26300 SW 131ST CT
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-8941
Mailing Address - Country:US
Mailing Address - Phone:786-523-6296
Mailing Address - Fax:
Practice Address - Street 1:26300 SW 131ST CT
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33032-8941
Practice Address - Country:US
Practice Address - Phone:786-523-6296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-10
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLF02230938363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty