Healthcare Provider Details

I. General information

NPI: 1215761648
Provider Name (Legal Business Name): MRS. NANCY ELENA MARTINEZ MORALES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2024
Last Update Date: 09/25/2024
Certification Date: 09/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12966 SW 133RD CT STE A
MIAMI FL
33186-6174
US

IV. Provider business mailing address

6245 KENDALE LAKES CIR APT A108
MIAMI FL
33183-1960
US

V. Phone/Fax

Practice location:
  • Phone: 305-255-6203
  • Fax: 305-255-6205
Mailing address:
  • Phone: 786-488-9422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-23-309097
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: