Healthcare Provider Details

I. General information

NPI: 1275177552
Provider Name (Legal Business Name): JUANA LIUDMILA MONTALVO DUPORTE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/30/2019
Last Update Date: 07/31/2023
Certification Date: 08/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8041 PLAZA DEL LAGO DR
ESTERO FL
33928-5300
US

IV. Provider business mailing address

806 GREENWOOD AVE
LEHIGH ACRES FL
33972-3026
US

V. Phone/Fax

Practice location:
  • Phone: 239-494-3460
  • Fax:
Mailing address:
  • Phone: 305-496-8234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9379496
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11005205
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: