Provider Demographics
NPI:1457628984
Name:MAHL, JENNIFER STEWART (APRN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:STEWART
Last Name:MAHL
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 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-312-3328
Mailing Address - Fax:321-409-3685
Practice Address - Street 1:1223 GATEWAY DR STE 1B
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2607
Practice Address - Country:US
Practice Address - Phone:321-312-3328
Practice Address - Fax:321-409-3685
Is Sole Proprietor?:No
Enumeration Date:2011-11-29
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9279191363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP01165524OtherFL RR MEDICARE
FL9484824OtherAETNA
FLY0A69OtherFLORIDA BLUE