Provider Demographics
NPI:1619405461
Name:BECERRA, CONSOLACION LICETH (RN-BC)
Entity Type:Individual
Prefix:MS
First Name:CONSOLACION
Middle Name:LICETH
Last Name:BECERRA
Suffix:
Gender:F
Credentials:RN-BC
Other - Prefix:MRS
Other - First Name:CONSOLACION
Other - Middle Name:LICETH
Other - Last Name:HUERFANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:100 PARK PLACE BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-2326
Mailing Address - Country:US
Mailing Address - Phone:407-766-4519
Mailing Address - Fax:
Practice Address - Street 1:100 PARK PLACE BLVD STE 201
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-2326
Practice Address - Country:US
Practice Address - Phone:407-766-4519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-24
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9175391163WP0808X
FL11025765363LA2200X, 363LG0600X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology