Healthcare Provider Details

I. General information

NPI: 1578223590
Provider Name (Legal Business Name): MARCOS JOSE CARVAJAL BERMEJO DNP, PMHNP-BC, APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2021
Last Update Date: 12/12/2024
Certification Date: 12/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16430 NW 59TH AVE STE 202
MIAMI LAKES FL
33014-5605
US

IV. Provider business mailing address

16430 NW 59TH AVE STE 202
MIAMI LAKES FL
33014-5605
US

V. Phone/Fax

Practice location:
  • Phone: 754-201-5811
  • Fax:
Mailing address:
  • Phone: 786-638-1508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN11017076
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberAPRN11017076
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: