Healthcare Provider Details

I. General information

NPI: 1275359119
Provider Name (Legal Business Name): YISEET FAJARDO DIAZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2024
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 PICO CT
LAKELAND FL
33809-4234
US

IV. Provider business mailing address

315 PICO CT
LAKELAND FL
33809-4234
US

V. Phone/Fax

Practice location:
  • Phone: 863-602-2594
  • Fax:
Mailing address:
  • Phone: 863-602-2594
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-375422
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: