Healthcare Provider Details

I. General information

NPI: 1841117611
Provider Name (Legal Business Name): ETHEREAL MEDSPA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2026
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13011 SW 132ND ST
MIAMI FL
33186-7197
US

IV. Provider business mailing address

13011 SW 132ND ST
MIAMI FL
33186-7197
US

V. Phone/Fax

Practice location:
  • Phone: 786-804-1241
  • Fax:
Mailing address:
  • Phone: 786-804-1241
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ISABEL MARIA GOMEZ HERNANDEZ
Title or Position: APRN
Credential: APRN
Phone: 786-804-1241