Healthcare Provider Details

I. General information

NPI: 1639922602
Provider Name (Legal Business Name): YSDALY VIRGINIA THIELEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2024
Last Update Date: 05/03/2024
Certification Date: 05/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3812 SW 8TH ST
CORAL GABLES FL
33134-3002
US

IV. Provider business mailing address

3812 SW 8TH ST
CORAL GABLES FL
33134-3002
US

V. Phone/Fax

Practice location:
  • Phone: 305-747-9465
  • Fax: 786-981-5957
Mailing address:
  • Phone: 305-747-9765
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: