Healthcare Provider Details

I. General information

NPI: 1003407008
Provider Name (Legal Business Name): NISSA CRUZ-VICKERS FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2021
Last Update Date: 07/21/2022
Certification Date: 07/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10000 W COLONIAL DR
OCOEE FL
34761-3400
US

IV. Provider business mailing address

9500 S DADELAND BLVD STE 200
MIAMI FL
33156-2866
US

V. Phone/Fax

Practice location:
  • Phone: 407-296-1000
  • Fax:
Mailing address:
  • Phone: 305-468-4185
  • Fax: 305-675-3378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11011142
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: