Provider Demographics
NPI:1669582821
Name:PHELPS, JAN DENICE (ARNP)
Entity type:Individual
Prefix:MRS
First Name:JAN
Middle Name:DENICE
Last Name:PHELPS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2553 MASON OAKS DR
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33596-6498
Mailing Address - Country:US
Mailing Address - Phone:813-940-6046
Mailing Address - Fax:866-451-4607
Practice Address - Street 1:2553 MASON OAKS DR
Practice Address - Street 2:
Practice Address - City:VALRICO
Practice Address - State:FL
Practice Address - Zip Code:33596-6498
Practice Address - Country:US
Practice Address - Phone:813-940-6046
Practice Address - Fax:866-451-4607
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1851392363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1326237850OtherNPI BUSINESS
FL305568000Medicaid
FL1851392OtherLICENSE NUMBER
FL1669582821OtherNPI
FLP62395Medicare UPIN
FLE7385YMedicare ID - Type Unspecified