MEDICARE: MABEL MACIAS CRUZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	11024190	FL
2	363LF0000X	Family Nurse Practitioner	11024190	FL

General Provider Information

NPI Number	:	1467150458
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MABEL MACIAS CRUZ

Provider Business Mailing Address
First Line	:	815 PLANTATION WAY
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32404-8611
Country	:	US
Telephone Number	:	813-340-2819
Fax Number	:

Provider Business Practice Location Address
First Line	:	815 PLANTATION WAY
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32404-8611
Country	:	US
Telephone Number	:	813-340-2819
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/20/2023
Last Update Date	:	04/04/2023

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Directions to “ MABEL MACIAS CRUZ ” Practice Location

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