Provider Demographics
NPI:1639848419
Name:PONCE, JUAN C (APRN, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:C
Last Name:PONCE
Suffix:
Gender:M
Credentials:APRN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3501 DEL PRADO BLVD S STE 303
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33904-7222
Mailing Address - Country:US
Mailing Address - Phone:239-317-0265
Mailing Address - Fax:239-673-7681
Practice Address - Street 1:8323 NW 12TH ST STE 108
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33126-1839
Practice Address - Country:US
Practice Address - Phone:305-400-8511
Practice Address - Fax:305-392-0184
Is Sole Proprietor?:No
Enumeration Date:2021-09-07
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11012428101YM0800X, 363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL112093100Medicaid