Healthcare Provider Details

I. General information

NPI: 1760095525
Provider Name (Legal Business Name): DISELIA LOPEZ BLANCO FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2020
Last Update Date: 10/19/2024
Certification Date: 10/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1695 NW 110TH AVE STE 218
SWEETWATER FL
33172-1929
US

IV. Provider business mailing address

22905 SW 131ST AVE
MIAMI FL
33170-2775
US

V. Phone/Fax

Practice location:
  • Phone: 305-456-7580
  • Fax: 786-536-5689
Mailing address:
  • Phone: 786-942-2618
  • Fax: 786-536-5689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11010235
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: