Healthcare Provider Details

I. General information

NPI: 1134935976
Provider Name (Legal Business Name): VIVIANA LAZARA ESPINOSA HERNANDEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2024
Last Update Date: 12/21/2024
Certification Date: 12/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 NW 7TH ST
CAPE CORAL FL
33993-1806
US

IV. Provider business mailing address

123 NW 7TH ST
CAPE CORAL FL
33993-1806
US

V. Phone/Fax

Practice location:
  • Phone: 239-414-8423
  • Fax: 239-414-8423
Mailing address:
  • Phone: 239-414-8423
  • Fax: 239-414-8423

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-397118
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: