Healthcare Provider Details

I. General information

NPI: 1639073083
Provider Name (Legal Business Name): AVELLAIL DIAZ PRIETO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2026
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21961 SW 124TH AVE
MIAMI FL
33170-2794
US

IV. Provider business mailing address

21961 SW 124TH AVE
MIAMI FL
33170-2794
US

V. Phone/Fax

Practice location:
  • Phone: 786-278-3780
  • Fax:
Mailing address:
  • Phone: 786-278-3780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number27034
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: