Provider Demographics
NPI:1558830562
Name:AGUILA DIAZ, YISEL MARCELINA
Entity Type:Individual
Prefix:
First Name:YISEL
Middle Name:MARCELINA
Last Name:AGUILA DIAZ
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 1:811 NW 131ST AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33182-2397
Mailing Address - Country:US
Mailing Address - Phone:305-766-3819
Mailing Address - Fax:
Practice Address - Street 1:811 NW 131ST AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33182-2397
Practice Address - Country:US
Practice Address - Phone:305-766-3819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-19
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11000193363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10181785Medicaid