Provider Demographics
NPI:1821489204
Name:VENZON, MARY JANE ALCANTARA (ARNP)
Entity Type:Individual
Prefix:
First Name:MARY JANE
Middle Name:ALCANTARA
Last Name:VENZON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1070 N STONE ST STE A
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-0824
Mailing Address - Country:US
Mailing Address - Phone:386-943-7100
Mailing Address - Fax:386-943-8909
Practice Address - Street 1:1070 N STONE ST STE A
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720
Practice Address - Country:US
Practice Address - Phone:386-943-7100
Practice Address - Fax:386-943-8909
Is Sole Proprietor?:No
Enumeration Date:2015-02-06
Last Update Date:2019-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAH119413363L00000X
FLAPRN9404408363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner