Provider Demographics
NPI:1689154940
Name:JARAMILLO, BERENICE B (PAC)
Entity Type:Individual
Prefix:
First Name:BERENICE
Middle Name:B
Last Name:JARAMILLO
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3028 BUCIDA DR
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34232-5443
Mailing Address - Country:US
Mailing Address - Phone:941-586-3040
Mailing Address - Fax:
Practice Address - Street 1:5432 BEE RIDGE RD STE 140
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34233-1512
Practice Address - Country:US
Practice Address - Phone:941-371-2244
Practice Address - Fax:941-371-1144
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-16
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9111737363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLVOOOLOtherBCBS FL
FL105002100Medicaid