Healthcare Provider Details

I. General information

NPI: 1174165724
Provider Name (Legal Business Name): CARLOS CARBONELL APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2019
Last Update Date: 03/12/2021
Certification Date: 03/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2750 W 68TH ST STE 127-128
HIALEAH FL
33016-5446
US

IV. Provider business mailing address

2750 W 68TH ST STE 127-128
HIALEAH FL
33016-5446
US

V. Phone/Fax

Practice location:
  • Phone: 786-351-4606
  • Fax:
Mailing address:
  • Phone: 305-558-0765
  • Fax: 305-558-0768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11004677
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: