Provider Demographics
NPI:1184860355
Name:DUQUE, TATIANA
Entity Type:Individual
Prefix:
First Name:TATIANA
Middle Name:
Last Name:DUQUE
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 1:721 SE 17TH ST
Mailing Address - Street 2:STE 104
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316-2983
Mailing Address - Country:US
Mailing Address - Phone:954-765-3200
Mailing Address - Fax:786-975-2643
Practice Address - Street 1:721 SE 17TH ST
Practice Address - Street 2:STE 104
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-2983
Practice Address - Country:US
Practice Address - Phone:954-765-3200
Practice Address - Fax:786-975-2643
Is Sole Proprietor?:No
Enumeration Date:2008-12-18
Last Update Date:2008-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA54274225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist