Healthcare Provider Details

I. General information

NPI: 1992474423
Provider Name (Legal Business Name): LISSETT GONZALEZ QUINTANA MA 93851
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2021
Last Update Date: 09/08/2021
Certification Date: 09/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8504 NW 103RD ST
HIALEAH FL
33016-4870
US

IV. Provider business mailing address

1245 W 25TH PL APT 3
HIALEAH FL
33010-1831
US

V. Phone/Fax

Practice location:
  • Phone: 786-420-5111
  • Fax:
Mailing address:
  • Phone: 786-379-3650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA93851
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: