Healthcare Provider Details

I. General information

NPI: 1558180844
Provider Name (Legal Business Name): NADINE BUERGO PALENZUELA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2024
Last Update Date: 10/04/2024
Certification Date: 10/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1219 SE 34TH ST
CAPE CORAL FL
33904-4291
US

IV. Provider business mailing address

1219 SE 34TH ST
CAPE CORAL FL
33904-4291
US

V. Phone/Fax

Practice location:
  • Phone: 239-703-3502
  • Fax:
Mailing address:
  • Phone: 239-703-3502
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-367692
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: