Healthcare Provider Details

I. General information

NPI: 1801675673
Provider Name (Legal Business Name): LIDISLAY GONZALEZ FUENTES ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2023
Last Update Date: 10/11/2024
Certification Date: 10/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 W 47TH ST
HIALEAH FL
33012-3317
US

IV. Provider business mailing address

1030 W 47TH ST
HIALEAH FL
33012-3317
US

V. Phone/Fax

Practice location:
  • Phone: 786-531-8250
  • Fax:
Mailing address:
  • Phone: 786-531-8250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF09230547
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11030508
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: