Provider Demographics
NPI:1083208599
Name:BLANCO ALONSO, MAYDIBIS
Entity Type:Individual
Prefix:MRS
First Name:MAYDIBIS
Middle Name:
Last Name:BLANCO ALONSO
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 1:14460 SW 50TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-5038
Mailing Address - Country:US
Mailing Address - Phone:786-380-8375
Mailing Address - Fax:
Practice Address - Street 1:2424 SW 137TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-6311
Practice Address - Country:US
Practice Address - Phone:786-300-6316
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-24
Last Update Date:2022-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11010046363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily