Healthcare Provider Details

I. General information

NPI: 1932801198
Provider Name (Legal Business Name): STEPHANIE MEDIAVILLA AGACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2023
Last Update Date: 06/04/2024
Certification Date: 06/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8950 N KENDALL DR
MIAMI FL
33176-2144
US

IV. Provider business mailing address

19741 NW 7TH CT
MIAMI GARDENS FL
33169-3175
US

V. Phone/Fax

Practice location:
  • Phone: 786-596-5959
  • Fax:
Mailing address:
  • Phone: 786-768-4978
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License NumberAPRN11025204
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: