Provider Demographics
NPI:1124592811
Name:FIESTAN, GILAINE (RN)
Entity Type:Individual
Prefix:
First Name:GILAINE
Middle Name:
Last Name:FIESTAN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:851 TRAFALGAR CT STE 200E
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7420
Mailing Address - Country:US
Mailing Address - Phone:407-667-0444
Mailing Address - Fax:407-667-4338
Practice Address - Street 1:601 E ROLLINS ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-1248
Practice Address - Country:US
Practice Address - Phone:407-667-0444
Practice Address - Fax:407-667-4338
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-15
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95033114163W00000X
FLAPRN11002919367500000X
FL9331382163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103425400Medicaid