Healthcare Provider Details

I. General information

NPI: 1700513595
Provider Name (Legal Business Name): MRS. ANA BRISEIDA BONILLA QUINONES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2022
Last Update Date: 08/02/2022
Certification Date: 08/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

561 SWALLOWTAIL DR
HAINES CITY FL
33844-7740
US

IV. Provider business mailing address

561 SWALLOWTAIL DR
HAINES CITY FL
33844-7740
US

V. Phone/Fax

Practice location:
  • Phone: 787-403-5512
  • Fax:
Mailing address:
  • Phone: 787-403-5512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number8436
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: