1710599832 NPI number — ELENA BLANCO BAEZ APRN 11008738

Table of content: ELENA BLANCO BAEZ APRN 11008738 (NPI 1710599832)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710599832 NPI number — ELENA BLANCO BAEZ APRN 11008738

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLANCO BAEZ
Provider First Name:
ELENA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN 11008738
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710599832
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1930 NW 94TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33147-3158
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
786-314-3605
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2141 SW 1ST ST STE 107
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIAMI
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33135-5601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-649-3336
Provider Business Practice Location Address Fax Number:
305-649-3929
Provider Enumeration Date:
08/19/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  11008738 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 109595500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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