Provider Demographics
NPI:1780801159
Name:GRAVELL MENDOZA, JENNIFER SUE (ARNP)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:SUE
Last Name:GRAVELL MENDOZA
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:SUE
Other - Last Name:MENDOZA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1405 JECENIA BLOSSOM DR
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32712-4437
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2000 PREVATT ST
Practice Address - Street 2:SUITE B3
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-6149
Practice Address - Country:US
Practice Address - Phone:321-273-0301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP-9238808363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLARNP-9238808OtherNURSE PRACTITINER LICENSE
2005010729OtherANCC FNP BD CERT