Healthcare Provider Details

I. General information

NPI: 1912860768
Provider Name (Legal Business Name): MAYULI DIAZ HERNANDEZ SA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2025
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14050 SW 91ST TER
MIAMI FL
33186-1293
US

IV. Provider business mailing address

14050 SW 91ST TER
MIAMI FL
33186-1293
US

V. Phone/Fax

Practice location:
  • Phone: 786-854-0240
  • Fax:
Mailing address:
  • Phone: 786-854-0240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number2977
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number25-296
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2977
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: