Healthcare Provider Details

I. General information

NPI: 1275025090
Provider Name (Legal Business Name): YUDISLEIDY PONCE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2018
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19610 SW 121ST AVE
MIAMI FL
33177-4351
US

IV. Provider business mailing address

19610 SW 121ST AVE
MIAMI FL
33177-4351
US

V. Phone/Fax

Practice location:
  • Phone: 786-818-3978
  • Fax:
Mailing address:
  • Phone: 786-818-3978
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11049771
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number1744149
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: