Provider Demographics
NPI:1477063741
Name:TAVERAS, JULISSA (ARNP)
Entity Type:Individual
Prefix:
First Name:JULISSA
Middle Name:
Last Name:TAVERAS
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 1:4371 VERONICA S SHOEMAKER BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33916-2216
Mailing Address - Country:US
Mailing Address - Phone:239-236-5711
Mailing Address - Fax:
Practice Address - Street 1:8260 GLADIOLUS DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-4156
Practice Address - Country:US
Practice Address - Phone:239-437-5755
Practice Address - Fax:239-437-5776
Is Sole Proprietor?:No
Enumeration Date:2017-10-02
Last Update Date:2017-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9380884363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner