Provider Demographics
NPI:1184292294
Name:DE LA VINA, JESSICA (APRN)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:
Last Name:DE LA VINA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 TREE SWALLOW DR APT 100
Mailing Address - Street 2:
Mailing Address - City:WINTER SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32708-6587
Mailing Address - Country:US
Mailing Address - Phone:407-927-9511
Mailing Address - Fax:
Practice Address - Street 1:1550 TREE SWALLOW DR APT 100
Practice Address - Street 2:
Practice Address - City:WINTER SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32708-6587
Practice Address - Country:US
Practice Address - Phone:407-927-9511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-15
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11013153207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine