Provider Demographics
NPI:1619603719
Name:IBASAN, JENNIFER (FNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:IBASAN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:BELLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4165 SUMMERVIEW WAY
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92056-3476
Mailing Address - Country:US
Mailing Address - Phone:786-546-5726
Mailing Address - Fax:
Practice Address - Street 1:4165 SUMMERVIEW WAY
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92056-3476
Practice Address - Country:US
Practice Address - Phone:786-546-5726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-29
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11010001363LF0000X
CA95021128363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily