Provider Demographics
NPI:1689246191
Name:MANZANARES ANGULO, MARIELA
Entity Type:Individual
Prefix:
First Name:MARIELA
Middle Name:
Last Name:MANZANARES ANGULO
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 1:13100 SW 55TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-6220
Mailing Address - Country:US
Mailing Address - Phone:786-803-4533
Mailing Address - Fax:
Practice Address - Street 1:801 NW 37TH AVE STE 207
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33125-3882
Practice Address - Country:US
Practice Address - Phone:786-953-7482
Practice Address - Fax:786-953-7467
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-14
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11014052363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1981OtherPOP
FL1981Medicaid