Provider Demographics
NPI:1609549013
Name:ISHMAEL, JEANINE
Entity Type:Individual
Prefix:
First Name:JEANINE
Middle Name:
Last Name:ISHMAEL
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 1:4181 SW HIGH MEADOWS AVE
Mailing Address - Street 2:
Mailing Address - City:PALM CITY
Mailing Address - State:FL
Mailing Address - Zip Code:34990-3725
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4181 SW HIGH MEADOWS AVE
Practice Address - Street 2:
Practice Address - City:PALM CITY
Practice Address - State:FL
Practice Address - Zip Code:34990-3725
Practice Address - Country:US
Practice Address - Phone:772-221-7620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-30
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11014373363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily