Provider Demographics
NPI:1629699491
Name:PEREA TRISTA, AMLENIS DE LA CARIDAD
Entity Type:Individual
Prefix:
First Name:AMLENIS
Middle Name:DE LA CARIDAD
Last Name:PEREA TRISTA
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 1:6590 SW 33RD ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-3954
Mailing Address - Country:US
Mailing Address - Phone:786-715-5925
Mailing Address - Fax:
Practice Address - Street 1:6590 SW 33RD ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-3954
Practice Address - Country:US
Practice Address - Phone:786-715-5925
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-02
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-21-13304106E00000X
FLAPRN11021206363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst