Provider Demographics
NPI:1578296034
Name:QUINTANILLA LEYVA, FERNANDO ALEXIS
Entity Type:Individual
Prefix:
First Name:FERNANDO
Middle Name:ALEXIS
Last Name:QUINTANILLA LEYVA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6217 38TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-1608
Mailing Address - Country:US
Mailing Address - Phone:727-623-1695
Mailing Address - Fax:
Practice Address - Street 1:6217 38TH AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-1608
Practice Address - Country:US
Practice Address - Phone:727-623-1695
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-02
Last Update Date:2022-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLF06222096363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily