Basic Information
| Provider Information | |||||||||
| NPI: | 1649247917 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIANA | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2675 WINKLER AVE FL 2 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339019342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778563774 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8093 NORMANDY BLVD | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322216646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046330640 | ||||||||
| FaxNumber: | 9046330641 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2006 | ||||||||
| LastUpdateDate: | 10/04/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9101519 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 2909626-00 | 05 | FL | MEDICAID | OA835 | 01 | FL | MEDICARE | OTHER |