Provider Demographics
NPI:1700777224
Name:MY DYNAMIC MEDICAL GROUP LLC
Entity type:Organization
Organization Name:MY DYNAMIC MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:APRN
Authorized Official - Prefix:
Authorized Official - First Name:IVETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:DIEGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-800-4563
Mailing Address - Street 1:420 DEL PRADO BLVD N STE 122
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33909-2211
Mailing Address - Country:US
Mailing Address - Phone:786-800-4563
Mailing Address - Fax:
Practice Address - Street 1:420 DEL PRADO BLVD N STE 122
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33909-2211
Practice Address - Country:US
Practice Address - Phone:786-800-4563
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-12
Last Update Date:2025-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty