Healthcare Provider Details

I. General information

NPI: 1528564648
Provider Name (Legal Business Name): MYRELLA LIZETH CUELLAR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2018
Last Update Date: 08/23/2024
Certification Date: 08/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1390 MILLER ST
HONOLULU HI
96813-2493
US

IV. Provider business mailing address

3771 STEFANI RD
CANTONMENT FL
32533-7795
US

V. Phone/Fax

Practice location:
  • Phone: 808-784-6200
  • Fax:
Mailing address:
  • Phone: 850-607-6910
  • Fax: 850-607-6932

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-18-52810
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: