Provider Demographics
NPI:1467051003
Name:CASANOVA MEDEROS, RAISELINE DE LA CARIDAD
Entity Type:Individual
Prefix:
First Name:RAISELINE
Middle Name:DE LA CARIDAD
Last Name:CASANOVA MEDEROS
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 1:120 NW 49TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-5132
Mailing Address - Country:US
Mailing Address - Phone:786-856-8472
Mailing Address - Fax:
Practice Address - Street 1:120 NW 49TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33126-5132
Practice Address - Country:US
Practice Address - Phone:786-856-8472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-24
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11009934363LF0000X
FLF10201243363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily