Provider Demographics
NPI:1871912071
Name:JONELLE RIVAS GIBSON ARNP PA
Entity type:Organization
Organization Name:JONELLE RIVAS GIBSON ARNP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JONELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:RIVAS GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-900-9804
Mailing Address - Street 1:250 S FEDERAL HWY STE 101
Mailing Address - Street 2:
Mailing Address - City:DANIA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33004-4005
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:250 S FEDERAL HWY STE 101
Practice Address - Street 2:
Practice Address - City:DANIA BEACH
Practice Address - State:FL
Practice Address - Zip Code:33004-4005
Practice Address - Country:US
Practice Address - Phone:954-900-9804
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-15
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9266389363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL007269700Medicaid