Healthcare Provider Details

I. General information

NPI: 1477464386
Provider Name (Legal Business Name): DENISE FIESTA
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 JOHNSON ST
HOLLYWOOD FL
33021-5421
US

IV. Provider business mailing address

10650 W STATE ROAD 84
DAVIE FL
33324-4235
US

V. Phone/Fax

Practice location:
  • Phone: 954-987-2000
  • Fax:
Mailing address:
  • Phone: 954-376-6142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS17406
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: