Provider Demographics
NPI:1790541852
Name:JIMENO-PERALTA, MARSELLA
Entity Type:Individual
Prefix:
First Name:MARSELLA
Middle Name:
Last Name:JIMENO-PERALTA
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 1:4105 SW 173RD AVE
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33029-5047
Mailing Address - Country:US
Mailing Address - Phone:754-610-7728
Mailing Address - Fax:
Practice Address - Street 1:1604 TOWN CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33326-3640
Practice Address - Country:US
Practice Address - Phone:954-349-2094
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-26
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11031504363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care