Healthcare Provider Details

I. General information

NPI: 1861275984
Provider Name (Legal Business Name): LEONARDO ENRIQUE DIEZ PEREZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2023
Last Update Date: 08/15/2023
Certification Date: 08/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

858 MONUMENT RD # P
JACKSONVILLE FL
32225-6670
US

IV. Provider business mailing address

3544 SAINT JOHNS BLUFF RD S APT 322
JACKSONVILLE FL
32224-2666
US

V. Phone/Fax

Practice location:
  • Phone: 904-450-8060
  • Fax:
Mailing address:
  • Phone: 786-580-8358
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11027991
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: