Provider Demographics
NPI:1356348189
Name:PANETTA, JILL MAUREEN (APRN)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:MAUREEN
Last Name:PANETTA
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 1:1876 TRADE CENTER WAY UNIT 100
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34109-1979
Mailing Address - Country:US
Mailing Address - Phone:203-379-7516
Mailing Address - Fax:
Practice Address - Street 1:1876 TRADE CENTER WAY UNIT 100
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34109-1979
Practice Address - Country:US
Practice Address - Phone:203-379-7516
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2021-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002564363L00000X, 363LA2100X
FL11005244363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
UNKNOWNOtherPRIVATE INSURANCE