Provider Demographics
NPI:1376278978
Name:LICEA, JENALYN VICTORIA (APRN)
Entity Type:Individual
Prefix:
First Name:JENALYN
Middle Name:VICTORIA
Last Name:LICEA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2050 FARM WAY
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:FL
Mailing Address - Zip Code:32068-6796
Mailing Address - Country:US
Mailing Address - Phone:864-334-7227
Mailing Address - Fax:
Practice Address - Street 1:2050 FARM WAY
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG
Practice Address - State:FL
Practice Address - Zip Code:32068-6796
Practice Address - Country:US
Practice Address - Phone:864-334-7227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-19
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11020852363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily