Provider Demographics
NPI:1689427197
Name:ICAZA, JEANNINE ANTONELLA (APRN)
Entity Type:Individual
Prefix:
First Name:JEANNINE
Middle Name:ANTONELLA
Last Name:ICAZA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10273 SW 116TH ST # AT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33176-4047
Mailing Address - Country:US
Mailing Address - Phone:786-218-6613
Mailing Address - Fax:
Practice Address - Street 1:1240 S DIXIE HWY
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33146-2902
Practice Address - Country:US
Practice Address - Phone:305-669-2833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-08
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11005030363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner