Provider Demographics
NPI:1083967806
Name:GORANOVIC, JOLENE KEIKO (AA-C)
Entity Type:Individual
Prefix:
First Name:JOLENE
Middle Name:KEIKO
Last Name:GORANOVIC
Suffix:
Gender:F
Credentials:AA-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 2400
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32902-2400
Mailing Address - Country:US
Mailing Address - Phone:321-255-9671
Mailing Address - Fax:
Practice Address - Street 1:1304 OAK ST
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3111
Practice Address - Country:US
Practice Address - Phone:321-723-4723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-17
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAA 132367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant