Provider Demographics
NPI:1174197164
Name:ETTIENE, JAVAN
Entity Type:Individual
Prefix:
First Name:JAVAN
Middle Name:
Last Name:ETTIENE
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 1:7904 LASALLE BLVD
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33023-4500
Mailing Address - Country:US
Mailing Address - Phone:954-934-4265
Mailing Address - Fax:
Practice Address - Street 1:7904 LASALLE BLVD
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33023-4500
Practice Address - Country:US
Practice Address - Phone:954-934-4265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-14
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11013397363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty