Provider Demographics
NPI:1891019063
Name:FACCIOLI, JENNIFER ELLEN (ARNP)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:ELLEN
Last Name:FACCIOLI
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 1:725 107TH AVE N
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34108-1858
Mailing Address - Country:US
Mailing Address - Phone:239-248-8695
Mailing Address - Fax:
Practice Address - Street 1:1425 CREECH RD
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34103-4207
Practice Address - Country:US
Practice Address - Phone:239-262-8923
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-17
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1756682364SW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SW0102XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL034947000Medicaid
P63440OtherUPIN
Y54002Medicare PIN