Provider Demographics
NPI:1114457579
Name:VALLEJO, PRISCILLA DULCE (PA-C)
Entity Type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:DULCE
Last Name:VALLEJO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8001 SW 36TH ST STE 9
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33328-1915
Mailing Address - Country:US
Mailing Address - Phone:954-577-7790
Mailing Address - Fax:954-577-7780
Practice Address - Street 1:16250 NW 57TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33014
Practice Address - Country:US
Practice Address - Phone:786-442-2136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-18
Last Update Date:2023-12-21
Deactivation Date:2023-11-13
Deactivation Code:
Reactivation Date:2023-12-21
Provider Licenses
StateLicense IDTaxonomies
FLPA9118087363AM0700X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty