Healthcare Provider Details

I. General information

NPI: 1477487502
Provider Name (Legal Business Name): BLANCA ROSA IBARRA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BLANCA ROSA DIAZ

II. Dates (important events)

Enumeration Date: 06/12/2026
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3909 CARAMBOLA CIR N
COCONUT CREEK FL
33066-2403
US

IV. Provider business mailing address

3909 CARAMBOLA CIR N
COCONUT CREEK FL
33066-2403
US

V. Phone/Fax

Practice location:
  • Phone: 786-873-2910
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11048283
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: