Healthcare Provider Details

I. General information

NPI: 1710810635
Provider Name (Legal Business Name): MIDAELLE PHANOR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15150 NW 79TH CT STE 100
MIAMI LAKES FL
33016-5870
US

IV. Provider business mailing address

582 E 85TH ST
BROOKLYN NY
11236-3249
US

V. Phone/Fax

Practice location:
  • Phone: 305-821-0502
  • Fax:
Mailing address:
  • Phone: 347-469-4038
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: