Provider Demographics
NPI:1467699256
Name:JALICE, MARLENE (ARNP)
Entity Type:Individual
Prefix:
First Name:MARLENE
Middle Name:
Last Name:JALICE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4125 W 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-5874
Mailing Address - Country:US
Mailing Address - Phone:305-424-3120
Mailing Address - Fax:
Practice Address - Street 1:4125 W 20TH AVE
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-5874
Practice Address - Country:US
Practice Address - Phone:305-424-3120
Practice Address - Fax:305-424-3182
Is Sole Proprietor?:No
Enumeration Date:2009-01-15
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9243340363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001486400Medicaid