Provider Demographics
NPI:1659026235
Name:LEIVA DEPESTRE, MARIA ISABEL
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:ISABEL
Last Name:LEIVA DEPESTRE
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 1:730 E 44TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33013-1918
Mailing Address - Country:US
Mailing Address - Phone:786-458-3407
Mailing Address - Fax:
Practice Address - Street 1:730 E 44TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33013-1918
Practice Address - Country:US
Practice Address - Phone:786-458-3407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-13
Last Update Date:2022-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11015087363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner