Healthcare Provider Details

I. General information

NPI: 1548929375
Provider Name (Legal Business Name): VANESSA MIJARES RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2021
Last Update Date: 12/09/2021
Certification Date: 12/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5201 RAYMOND ST
ORLANDO FL
32803-8208
US

IV. Provider business mailing address

10344 WINDING CREEK LN
ORLANDO FL
32825-7320
US

V. Phone/Fax

Practice location:
  • Phone: 407-719-6456
  • Fax:
Mailing address:
  • Phone: 772-214-8176
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: