Provider Demographics
NPI:1023615507
Name:LEITE DA SILVA, JENISSA DENEE (PA-C)
Entity type:Individual
Prefix:
First Name:JENISSA
Middle Name:DENEE
Last Name:LEITE DA SILVA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 935921
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-5921
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:61 MEMORIAL MEDICAL PKWY STE 2811
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-5999
Practice Address - Country:US
Practice Address - Phone:386-586-1870
Practice Address - Fax:386-586-1872
Is Sole Proprietor?:No
Enumeration Date:2020-10-07
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9113699363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOE838OtherMEDICARE HF