Provider Demographics
NPI:1851743199
Name:DEJESUS, MAYRA (ARNP)
Entity Type:Individual
Prefix:
First Name:MAYRA
Middle Name:
Last Name:DEJESUS
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 1:1792 MEADOWGOLD LN
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-6364
Mailing Address - Country:US
Mailing Address - Phone:407-256-3715
Mailing Address - Fax:
Practice Address - Street 1:10739 DEERWOOD PARK BLVD STE 200
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-4839
Practice Address - Country:US
Practice Address - Phone:904-719-7707
Practice Address - Fax:800-266-5158
Is Sole Proprietor?:No
Enumeration Date:2016-07-11
Last Update Date:2018-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2114722364SG0600X
FLARNP2114722363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontology