Provider Demographics
NPI:1710540125
Name:DEJESUS, CHRISTINE MARIE
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:MARIE
Last Name:DEJESUS
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 1:121 S ORANGE AVE STE 940
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32801-3234
Mailing Address - Country:US
Mailing Address - Phone:321-332-6947
Mailing Address - Fax:407-286-4515
Practice Address - Street 1:21 S CHARLES RICHARD BEALL BLVD
Practice Address - Street 2:
Practice Address - City:DEBARY
Practice Address - State:FL
Practice Address - Zip Code:32713-3342
Practice Address - Country:US
Practice Address - Phone:386-516-0990
Practice Address - Fax:386-668-6997
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-22
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9113801363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty