Basic Information
| Provider Information | |||||||||
| NPI: | 1629323407 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAZORRA | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3190 29TH AVE SW | ||||||||
| Address2: | |||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341178418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2398214932 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 625 9TH ST N | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341028143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392612000 | ||||||||
| FaxNumber: | 2392612266 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2012 | ||||||||
| LastUpdateDate: | 07/31/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | ARNP 9266223 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | ARNP 9266223 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | RN9266223 | 01 | FL | FLORIDA BOARD OF NURSING | OTHER |