Provider Demographics
NPI:1528566379
Name:PIMENTEL DEL SOL, MADELAINE
Entity Type:Individual
Prefix:
First Name:MADELAINE
Middle Name:
Last Name:PIMENTEL DEL SOL
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 1:12171 SW 268TH ST
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-8001
Mailing Address - Country:US
Mailing Address - Phone:305-278-0200
Mailing Address - Fax:
Practice Address - Street 1:11211 N NEBRASKA AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-5777
Practice Address - Country:US
Practice Address - Phone:813-514-2333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-26
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11009863363LF0000X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1043635972Medicaid