Basic Information
| Provider Information | |||||||||
| NPI: | 1306106844 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AVILA | ||||||||
| FirstName: | JESSICA | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2900 CORPORATE WAY | ||||||||
| Address2: | DOOR D | ||||||||
| City: | MIRAMAR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330253925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542765685 | ||||||||
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| Practice Location | |||||||||
| Address1: | 603 N FLAMINGO ROAD | ||||||||
| Address2: | STE 157 | ||||||||
| City: | PEMBROKE PINES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542654325 | ||||||||
| FaxNumber: | 9544385191 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2012 | ||||||||
| LastUpdateDate: | 03/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | ARNP 9250148 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 017950300 | 05 | FL | MEDICAID |