Healthcare Provider Details

I. General information

NPI: 1003671629
Provider Name (Legal Business Name): DIANA ISABEL CLAVIJO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2024
Last Update Date: 05/16/2026
Certification Date: 05/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1170 SW BAYSHORE BLVD STE 100
PORT ST LUCIE FL
34983-2408
US

IV. Provider business mailing address

1170 SW BAYSHORE BLVD STE 100
PORT ST LUCIE FL
34983-2408
US

V. Phone/Fax

Practice location:
  • Phone: 772-309-0030
  • Fax: 855-538-2084
Mailing address:
  • Phone: 772-309-0030
  • Fax: 855-538-2084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11030622
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: