Healthcare Provider Details

I. General information

NPI: 1851199202
Provider Name (Legal Business Name): MRS. MAIDELY VANESSA LLANOS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2025
Last Update Date: 10/23/2025
Certification Date: 10/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1270 N WICKHAM RD STE 13
MELBOURNE FL
32935-8307
US

IV. Provider business mailing address

6760 BENSON AVE
COCOA FL
32927-3947
US

V. Phone/Fax

Practice location:
  • Phone: 321-324-3826
  • Fax:
Mailing address:
  • Phone: 321-324-3826
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-25-415223
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: