MEDICARE: MISS ANA IVIS CABRERA GONZALEZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	11000095	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	7P8TK	OTHER	FL	BCBS
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1912470709
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS ANA IVIS CABRERA GONZALEZ

Provider Business Mailing Address
First Line	:	13240 N CLEVELAND AVE STE 2&3
Second Line	:
City	:	NORTH FORT MYERS
State	:	FL
Zip	:	33903-4855
Country	:	US
Telephone Number	:	239-599-4986
Fax Number	:	239-205-6101

Provider Business Practice Location Address
First Line	:	13240 N CLEVELAND AVE STE 2-3
Second Line	:
City	:	NORTH FORT MYERS
State	:	FL
Zip	:	33903-4855
Country	:	US
Telephone Number	:	786-346-0178
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/04/2019
Last Update Date	:	09/04/2020

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