Provider Demographics
NPI:1497324396
Name:CRUZ, IVELISSE (APRN)
Entity Type:Individual
Prefix:
First Name:IVELISSE
Middle Name:
Last Name:CRUZ
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:IVELISSE
Other - Middle Name:
Other - Last Name:CRUZ CARRASQUILLO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:APRN
Mailing Address - Street 1:6100 BLUE LAGOON DR STE 365
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-7010
Mailing Address - Country:US
Mailing Address - Phone:786-322-7333
Mailing Address - Fax:786-347-5022
Practice Address - Street 1:5615 S FLORIDA AVE STE 111
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-2714
Practice Address - Country:US
Practice Address - Phone:863-327-0132
Practice Address - Fax:863-777-2320
Is Sole Proprietor?:No
Enumeration Date:2021-06-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11011713363LP0200X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL113978600Medicaid