Healthcare Provider Details

I. General information

NPI: 1114748548
Provider Name (Legal Business Name): LILIAN DANIELA MAIRENA PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2024
Last Update Date: 10/18/2024
Certification Date: 10/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7710 S US HIGHWAY 1
PORT ST LUCIE FL
34952-2320
US

IV. Provider business mailing address

7710 S US HIGHWAY 1
PORT ST LUCIE FL
34952-2320
US

V. Phone/Fax

Practice location:
  • Phone: 772-335-5300
  • Fax: 772-200-2131
Mailing address:
  • Phone: 772-335-5300
  • Fax: 772-200-2131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9119460
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: