Healthcare Provider Details

I. General information

NPI: 1922714146
Provider Name (Legal Business Name): THERESA VALENTINA CALIXTE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2023
Last Update Date: 10/26/2024
Certification Date: 10/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 S UNIVERSITY DR
DAVIE FL
33328-2018
US

IV. Provider business mailing address

14040 NE 8TH AVE
NORTH MIAMI FL
33161-3263
US

V. Phone/Fax

Practice location:
  • Phone: 954-262-1250
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9119334
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: