Healthcare Provider Details

I. General information

NPI: 1750238929
Provider Name (Legal Business Name): MARIANA CAROLINA RUIZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2026
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 MAR WALT DR
FORT WALTON BEACH FL
32547-6707
US

IV. Provider business mailing address

555 LIBERTY LN NW UNIT 301
FORT WALTON BEACH FL
32547-1491
US

V. Phone/Fax

Practice location:
  • Phone: 850-863-6600
  • Fax: 850-862-0977
Mailing address:
  • Phone: 786-291-2644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11045855
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: