Provider Demographics
NPI:1902389471
Name:INNIS, JAMIE LYNN (PA)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:LYNN
Last Name:INNIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 ROMANO AVE
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134-7246
Mailing Address - Country:US
Mailing Address - Phone:734-660-0114
Mailing Address - Fax:
Practice Address - Street 1:314 ROMANO AVE
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134
Practice Address - Country:US
Practice Address - Phone:734-660-0114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-11
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9111601363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant