Provider Demographics
NPI:1407556376
Name:GUEVARA, FIORDALIZA
Entity Type:Individual
Prefix:
First Name:FIORDALIZA
Middle Name:
Last Name:GUEVARA
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 1:2848 PORTER DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-7119
Mailing Address - Country:US
Mailing Address - Phone:678-770-4766
Mailing Address - Fax:
Practice Address - Street 1:2771 CRUZ ROAD
Practice Address - Street 2:SUITE 2
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-3004
Practice Address - Country:US
Practice Address - Phone:678-770-4766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-08
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMTO11772225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist