Provider Demographics
NPI:1104359215
Name:BANUELOS, JENNIFER (ARNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BANUELOS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3372 WOODS EDGE CIR STE 101
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34134-3436
Mailing Address - Country:US
Mailing Address - Phone:239-799-7873
Mailing Address - Fax:
Practice Address - Street 1:43 BARKLEY CIR STE 201
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-7518
Practice Address - Country:US
Practice Address - Phone:239-936-5250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-05
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9227695363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health