Healthcare Provider Details

I. General information

NPI: 1598354201
Provider Name (Legal Business Name): ELISA FERNANDA VELEZ POLIT SA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2021
Last Update Date: 01/16/2021
Certification Date: 01/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4114 STAGHORN LN
WESTON FL
33331-3804
US

IV. Provider business mailing address

4114 STAGHORN LN
WESTON FL
33331-3804
US

V. Phone/Fax

Practice location:
  • Phone: 954-646-5355
  • Fax:
Mailing address:
  • Phone: 954-646-5355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number20-518
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: