Provider Demographics
NPI:1043710288
Name:BANUELOS PSYCHIATRIC MENTAL HEALTHCARE LLC
Entity type:Organization
Organization Name:BANUELOS PSYCHIATRIC MENTAL HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:BANUELOS
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:850-983-8500
Mailing Address - Street 1:6061 DOCTORS PARK
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32570-5073
Mailing Address - Country:US
Mailing Address - Phone:850-983-8500
Mailing Address - Fax:850-983-0009
Practice Address - Street 1:6061 DOCTORS PARK
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32570-5073
Practice Address - Country:US
Practice Address - Phone:850-983-8500
Practice Address - Fax:850-983-0009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-14
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020592000Medicaid