Provider Demographics
NPI:1659850501
Name:CUELLAR, JACQUELINE TATIANA (APRN)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:TATIANA
Last Name:CUELLAR
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9421 S ORANGE BLOSSOM TRL # 19
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32837-8320
Mailing Address - Country:US
Mailing Address - Phone:407-601-2527
Mailing Address - Fax:
Practice Address - Street 1:8260 W FLAGLER ST STE 2I
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33144-2069
Practice Address - Country:US
Practice Address - Phone:786-715-9183
Practice Address - Fax:786-713-1115
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-11
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9406046207Q00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL19961979OtherNON-MEDICARE