Healthcare Provider Details

I. General information

NPI: 1063070340
Provider Name (Legal Business Name): ELISA N MASTROMARINO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2019
Last Update Date: 11/23/2021
Certification Date: 11/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 NW 17TH ST
MIAMI FL
33136-1119
US

IV. Provider business mailing address

900 NW 17TH ST
MIAMI FL
33136-1119
US

V. Phone/Fax

Practice location:
  • Phone: 305-326-6543
  • Fax: 305-326-6563
Mailing address:
  • Phone: 305-326-6543
  • Fax: 305-326-6563

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9388755
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN11003556
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: