Provider Demographics
NPI:1518355478
Name:ETTIENNE, IDANIA LISSETTE (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:IDANIA
Middle Name:LISSETTE
Last Name:ETTIENNE
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 1:6806 BLOOMFIELD GROVE PL
Mailing Address - Street 2:
Mailing Address - City:SEFFNER
Mailing Address - State:FL
Mailing Address - Zip Code:33584-2522
Mailing Address - Country:US
Mailing Address - Phone:813-418-0717
Mailing Address - Fax:
Practice Address - Street 1:907 N PARSONS AVE
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33510-3107
Practice Address - Country:US
Practice Address - Phone:813-689-8020
Practice Address - Fax:813-689-8381
Is Sole Proprietor?:No
Enumeration Date:2014-12-30
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9211883363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015021300Medicaid
FLIF520ZMedicare PIN