Provider Demographics
NPI:1164049250
Name:CELICOURT, JEAN ROBERT CELICOURT
Entity Type:Individual
Prefix:
First Name:JEAN ROBERT
Middle Name:CELICOURT
Last Name:CELICOURT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 SW 82ND AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33068-3512
Mailing Address - Country:US
Mailing Address - Phone:917-562-9516
Mailing Address - Fax:
Practice Address - Street 1:1409 SW 82ND AVE
Practice Address - Street 2:
Practice Address - City:NORTH LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33068-3512
Practice Address - Country:US
Practice Address - Phone:917-562-9516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-06
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11007843363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily