Provider Demographics
NPI:1740794643
Name:VILLAMIZAR, NAIROBI
Entity Type:Individual
Prefix:
First Name:NAIROBI
Middle Name:
Last Name:VILLAMIZAR
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:PO BOX 1554
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-1554
Mailing Address - Country:US
Mailing Address - Phone:352-508-5243
Mailing Address - Fax:352-602-4142
Practice Address - Street 1:2050 CLASSIQUE LN
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-5787
Practice Address - Country:US
Practice Address - Phone:352-508-5243
Practice Address - Fax:352-602-4142
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-30
Last Update Date:2017-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty