Healthcare Provider Details

I. General information

NPI: 1619692621
Provider Name (Legal Business Name): MARTINE GUSTAVE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2022
Last Update Date: 10/11/2022
Certification Date: 10/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1951 SW 172ND AVE STE 305
MIRAMAR FL
33029-5614
US

IV. Provider business mailing address

9675 NW 19TH PL
SUNRISE FL
33322-3604
US

V. Phone/Fax

Practice location:
  • Phone: 954-362-2720
  • Fax: 954-362-2762
Mailing address:
  • Phone: 786-362-0543
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11012985
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: