Provider Demographics
NPI:1932617297
Name:DRAGON, JIMMEVANS
Entity Type:Individual
Prefix:
First Name:JIMMEVANS
Middle Name:
Last Name:DRAGON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3451 COMMODORE CT
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33411-6483
Mailing Address - Country:US
Mailing Address - Phone:863-513-5069
Mailing Address - Fax:
Practice Address - Street 1:2054 VISTA PKWY STE 414
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33411-6741
Practice Address - Country:US
Practice Address - Phone:863-513-5069
Practice Address - Fax:863-513-5069
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-19
Last Update Date:2018-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN5200970164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse