Provider Demographics
NPI:1497266944
Name:JIMENEZ, MIRELYS
Entity Type:Individual
Prefix:
First Name:MIRELYS
Middle Name:
Last Name:JIMENEZ
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 1:50 W 33RD ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-5222
Mailing Address - Country:US
Mailing Address - Phone:786-307-0497
Mailing Address - Fax:305-742-2190
Practice Address - Street 1:50 W 33RD ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-5222
Practice Address - Country:US
Practice Address - Phone:786-307-0497
Practice Address - Fax:305-742-2190
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-23
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11030672363LP0808X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician