Provider Demographics
NPI:1053814806
Name:RACEDO, LUZ MARINA
Entity Type:Individual
Prefix:
First Name:LUZ MARINA
Middle Name:
Last Name:RACEDO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 S ORANGE AVE STE 940
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32801-3234
Mailing Address - Country:US
Mailing Address - Phone:407-658-9687
Mailing Address - Fax:407-286-4515
Practice Address - Street 1:811 N NOWELL ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32808-7538
Practice Address - Country:US
Practice Address - Phone:407-274-9590
Practice Address - Fax:407-290-9509
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-16
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9244232363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily