Healthcare Provider Details

I. General information

NPI: 1104157684
Provider Name (Legal Business Name): DIANE VELMORTH SEWELL-MENTORE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2010
Last Update Date: 01/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

651 E 25TH ST
HIALEAH FL
33013-3814
US

IV. Provider business mailing address

13485 SW 22ND ST
MIRAMAR FL
33027-2675
US

V. Phone/Fax

Practice location:
  • Phone: 305-835-4423
  • Fax:
Mailing address:
  • Phone: 954-441-5816
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number3304172
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: