Provider Demographics
NPI:1679240733
Name:VILLAVICENCIO, JUANA MARI (CLD)
Entity Type:Individual
Prefix:
First Name:JUANA
Middle Name:MARI
Last Name:VILLAVICENCIO
Suffix:
Gender:F
Credentials:CLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 GATEWAY CENTRE BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:PINELLAS PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33782-6141
Mailing Address - Country:US
Mailing Address - Phone:727-798-8993
Mailing Address - Fax:
Practice Address - Street 1:4000 GATEWAY CENTRE BLVD STE 200
Practice Address - Street 2:
Practice Address - City:PINELLAS PARK
Practice Address - State:FL
Practice Address - Zip Code:33782-6141
Practice Address - Country:US
Practice Address - Phone:727-798-8993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-26
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2013-189374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula