Healthcare Provider Details

I. General information

NPI: 1720696446
Provider Name (Legal Business Name): KRISTAL MARIE MARQUEZ
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

3201 BUDINGER AVE
SAINT CLOUD FL
34769-7203
US

IV. Provider business mailing address

1875 RED CANYON DR
KINDRED FL
34744-6091
US

V. Phone/Fax

Practice location:
  • Phone: 407-910-2941
  • Fax:
Mailing address:
  • Phone: 407-744-4565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number4424
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: