Healthcare Provider Details

I. General information

NPI: 1265104277
Provider Name (Legal Business Name): MILEIDIS ROQUE PUENTES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2021
Last Update Date: 09/29/2021
Certification Date: 09/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 W 84TH ST
HIALEAH FL
33014-3616
US

IV. Provider business mailing address

8520 NW 139TH TER APT 1602
MIAMI LAKES FL
33016-6703
US

V. Phone/Fax

Practice location:
  • Phone: 305-817-2900
  • Fax:
Mailing address:
  • Phone: 786-443-2555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11015574
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: