Provider Demographics
NPI:1558706424
Name:TEJERA, DALISSA MARIE
Entity Type:Individual
Prefix:
First Name:DALISSA
Middle Name:MARIE
Last Name:TEJERA
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 1:1475 NW 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33136-1002
Mailing Address - Country:US
Mailing Address - Phone:305-243-9136
Mailing Address - Fax:
Practice Address - Street 1:1475 NW 12TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1002
Practice Address - Country:US
Practice Address - Phone:305-243-9136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-06
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9288695363LA2200X
FLARNP9288695363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL4668245OtherAETNA
FLQMP000003701324OtherMOLINA HEALTHCARE
FLP1008781OtherFREEDOM HEALTH
FLY0J0DOtherBCBS OF FL
FLP948501OtherOPTIMUM
FLP1008781OtherFREEDOM HEALTH
FLHL115YMedicare PIN