Healthcare Provider Details

I. General information

NPI: 1619585288
Provider Name (Legal Business Name): MADELINE VEGA BERRIOS REGISTER NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2020
Last Update Date: 07/20/2020
Certification Date: 07/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1714 E IRLO BRONSON MEMORIAL HWY STE A
SAINT CLOUD FL
34771-5836
US

IV. Provider business mailing address

1714 E IRLO BRONSON MEMORIAL HWY STE A
SAINT CLOUD FL
34771-5836
US

V. Phone/Fax

Practice location:
  • Phone: 407-583-4795
  • Fax: 407-583-6412
Mailing address:
  • Phone: 407-583-4795
  • Fax: 407-583-6412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number9390051
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: