Healthcare Provider Details

I. General information

NPI: 1417762972
Provider Name (Legal Business Name): LIETTY CUELLAR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2025
Last Update Date: 03/17/2025
Certification Date: 02/11/2025
Deactivation Date: 03/07/2025
Reactivation Date: 03/17/2025

III. Provider practice location address

6036 NW 194TH ST
HIALEAH FL
33015-4812
US

IV. Provider business mailing address

6036 NW 194TH ST
HIALEAH FL
33015-4812
US

V. Phone/Fax

Practice location:
  • Phone: 305-775-0728
  • Fax:
Mailing address:
  • Phone: 305-775-0728
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF02250408
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: