Healthcare Provider Details

I. General information

NPI: 1205357076
Provider Name (Legal Business Name): BERTHA CORUJO RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

935 NW 15TH AVE
MIAMI FL
33125-3625
US

IV. Provider business mailing address

935 NW 15TH AVE
MIAMI FL
33125-3625
US

V. Phone/Fax

Practice location:
  • Phone: 305-775-6056
  • Fax:
Mailing address:
  • Phone: 305-775-6056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WX0200X
TaxonomyOncology Registered Nurse
License NumberRN3170112
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: