Provider Demographics
NPI:1477535144
Name:PLAZA, MARIANNETTE (NP)
Entity Type:Individual
Prefix:MISS
First Name:MARIANNETTE
Middle Name:
Last Name:PLAZA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1255 STATE ROAD 60 E STE 300
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33853-4310
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1255 STATE ROAD 60 E STE 300
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853
Practice Address - Country:US
Practice Address - Phone:863-259-6534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-17
Last Update Date:2018-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9408302363LX0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LX0106XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerOccupational HealthGroup - Single Specialty