Provider Demographics
NPI:1811251911
Name:LAFAILLE, JIMMY (DNP, APRN, FNP-BC)
Entity type:Individual
Prefix:DR
First Name:JIMMY
Middle Name:
Last Name:LAFAILLE
Suffix:
Gender:F
Credentials:DNP, APRN, FNP-BC
Other - Prefix:DR
Other - First Name:JIMMY
Other - Middle Name:
Other - Last Name:LAFAILLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DNP, APRN, PMHNP-BC
Mailing Address - Street 1:200 KNUTH RD STE 214B
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33436-4636
Mailing Address - Country:US
Mailing Address - Phone:561-374-2472
Mailing Address - Fax:949-404-8191
Practice Address - Street 1:200 KNUTH RD STE 214B
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33436-4636
Practice Address - Country:US
Practice Address - Phone:561-374-2472
Practice Address - Fax:949-404-8191
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-03
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9183076363L00000X
FLARNP 9183076363LF0000X
FL9183076363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1811251911Medicare UPIN