Provider Demographics
NPI:1215392808
Name:MEDEROS, LISETTE (BS)
Entity Type:Individual
Prefix:
First Name:LISETTE
Middle Name:
Last Name:MEDEROS
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 SW 129TH PL
Mailing Address - Street 2:APT 209
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33184-2100
Mailing Address - Country:US
Mailing Address - Phone:786-473-6551
Mailing Address - Fax:
Practice Address - Street 1:800 SW 129TH PL
Practice Address - Street 2:APT 209
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33184-2100
Practice Address - Country:US
Practice Address - Phone:786-473-6551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-23
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker