Provider Demographics
NPI:1417524299
Name:COLLAZO CASTILLO, JOMAYRA JANICE
Entity Type:Individual
Prefix:
First Name:JOMAYRA
Middle Name:JANICE
Last Name:COLLAZO CASTILLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4221 DERBY PL
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-7562
Mailing Address - Country:US
Mailing Address - Phone:787-624-9372
Mailing Address - Fax:
Practice Address - Street 1:4221 DERBY PL
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-7562
Practice Address - Country:US
Practice Address - Phone:787-624-9372
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-09
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11013566363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily