Provider Demographics
NPI:1679234041
Name:ALFONSO, ALFONSO (RN)
Entity Type:Individual
Prefix:
First Name:ALFONSO
Middle Name:
Last Name:ALFONSO
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 NW 79TH AVE STE 227
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33122-1085
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2500 NW 79TH AVE STE 227
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33122-1085
Practice Address - Country:US
Practice Address - Phone:305-456-9396
Practice Address - Fax:786-796-0640
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-06
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9248794163WG0000X, 163WP0000X, 163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No163WP0000XNursing Service ProvidersRegistered NursePain Management