Healthcare Provider Details

I. General information

NPI: 1053814806
Provider Name (Legal Business Name): LUZ MARINA RACEDO-MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2018
Last Update Date: 12/26/2024
Certification Date: 12/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11925 BIRD DR
MIAMI FL
33175-3571
US

IV. Provider business mailing address

121 S ORANGE AVE STE 940
ORLANDO FL
32801-3234
US

V. Phone/Fax

Practice location:
  • Phone: 305-467-4442
  • Fax:
Mailing address:
  • Phone: 407-658-9687
  • Fax: 407-286-4515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN9244232
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: