Healthcare Provider Details

I. General information

NPI: 1194504753
Provider Name (Legal Business Name): NADEJISA EDELWEISS OTANEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2023
Last Update Date: 09/25/2023
Certification Date: 09/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4203 SW HIGH MEADOWS AVE
PALM CITY FL
34990-3726
US

IV. Provider business mailing address

2481 SE CALIGULA AVE
PORT SAINT LUCIE FL
34952-6802
US

V. Phone/Fax

Practice location:
  • Phone: 772-222-5560
  • Fax:
Mailing address:
  • Phone: 772-486-6801
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: