Healthcare Provider Details

I. General information

NPI: 1700517018
Provider Name (Legal Business Name): MARYLINE AMELIE SALIBA APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2022
Last Update Date: 12/05/2022
Certification Date: 12/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 NW 12TH AVE
MIAMI FL
33136-1003
US

IV. Provider business mailing address

1400 NW 12TH AVE
MIAMI FL
33136-1087
US

V. Phone/Fax

Practice location:
  • Phone: 954-214-2134
  • Fax:
Mailing address:
  • Phone: 305-325-5511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SG0600X
TaxonomyGerontology Clinical Nurse Specialist
License Number11016630
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number11016630
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number11016630
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: