Healthcare Provider Details

I. General information

NPI: 1053146621
Provider Name (Legal Business Name): LILIET INZA SAN JOSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2024
Last Update Date: 09/04/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

708 GOODLETTE-FRANK RD N STE 1
NAPLES FL
34102-5644
US

IV. Provider business mailing address

33 ROYAL COVE DR
NAPLES FL
34110-6360
US

V. Phone/Fax

Practice location:
  • Phone: 239-351-0675
  • Fax: 239-310-2045
Mailing address:
  • Phone: 239-316-9464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-363292
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: