Provider Demographics
NPI:1548909484
Name:PROVANCE ROJAS, ISMARA YANET
Entity type:Individual
Prefix:
First Name:ISMARA
Middle Name:YANET
Last Name:PROVANCE ROJAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5625 W 26TH CT APT 202
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33016-4781
Mailing Address - Country:US
Mailing Address - Phone:786-317-4546
Mailing Address - Fax:
Practice Address - Street 1:7101 W FLAGLER ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33144-2601
Practice Address - Country:US
Practice Address - Phone:786-388-9696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-31
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11019021363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily