Healthcare Provider Details

I. General information

NPI: 1912775123
Provider Name (Legal Business Name): LIDICE LEYVA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LIDICE ZAMORA DIAZ

II. Dates (important events)

Enumeration Date: 12/18/2023
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2669 FOREST HILL BLVD STE 100
WEST PALM BEACH FL
33406-5966
US

IV. Provider business mailing address

154 MONTEREY WAY
ROYAL PALM BEACH FL
33411-7801
US

V. Phone/Fax

Practice location:
  • Phone: 561-467-6560
  • Fax: 888-720-4595
Mailing address:
  • Phone: 561-248-9446
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number11030027
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: