Healthcare Provider Details

I. General information

NPI: 1316630197
Provider Name (Legal Business Name): VANESSA DE LA CRUZ FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2023
Last Update Date: 05/30/2023
Certification Date: 05/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4045 SW 108TH CT
MIAMI FL
33165-4825
US

IV. Provider business mailing address

4045 SW 108TH CT
MIAMI FL
33165-4825
US

V. Phone/Fax

Practice location:
  • Phone: 786-454-0220
  • Fax:
Mailing address:
  • Phone: 786-454-0220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number11026217
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: