Healthcare Provider Details

I. General information

NPI: 1114390291
Provider Name (Legal Business Name): GRETEL MONTANO PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2015
Last Update Date: 01/16/2024
Certification Date: 01/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7035 NW 173RD DR APT 1608
HIALEAH FL
33015-4080
US

IV. Provider business mailing address

845 W 75TH ST APT 304
HIALEAH FL
33014-4089
US

V. Phone/Fax

Practice location:
  • Phone: 786-296-5234
  • Fax:
Mailing address:
  • Phone: 786-296-5234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number11030505
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: