Healthcare Provider Details

I. General information

NPI: 1053178772
Provider Name (Legal Business Name): ELAINE VALLEJO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/29/2024
Last Update Date: 05/16/2024
Certification Date: 05/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5850 W FLAGLER ST
MIAMI FL
33144-3363
US

IV. Provider business mailing address

8040 SW 14TH TER
MIAMI FL
33144-5263
US

V. Phone/Fax

Practice location:
  • Phone: 305-263-9590
  • Fax: 305-263-9657
Mailing address:
  • Phone: 305-302-6033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11031427
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: