Provider Demographics
NPI:1275272189
Name:JEAN, MIRANA
Entity Type:Individual
Prefix:
First Name:MIRANA
Middle Name:
Last Name:JEAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MIRANA
Other - Middle Name:
Other - Last Name:JEAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:936 FORESTERIA DR
Mailing Address - Street 2:
Mailing Address - City:LAKE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33403-3106
Mailing Address - Country:US
Mailing Address - Phone:561-927-5411
Mailing Address - Fax:
Practice Address - Street 1:936 FORESTERIA DR
Practice Address - Street 2:
Practice Address - City:LAKE PARK
Practice Address - State:FL
Practice Address - Zip Code:33403-3106
Practice Address - Country:US
Practice Address - Phone:561-927-5411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-31
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11011715363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner