Provider Demographics
NPI:1861031072
Name:FUNDORA, ANELL BEATRIZ
Entity Type:Individual
Prefix:
First Name:ANELL
Middle Name:BEATRIZ
Last Name:FUNDORA
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 1:8828 NW 112TH TER
Mailing Address - Street 2:
Mailing Address - City:HIALEAH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33018-4534
Mailing Address - Country:US
Mailing Address - Phone:305-680-9629
Mailing Address - Fax:
Practice Address - Street 1:8828 NW 112TH TER
Practice Address - Street 2:
Practice Address - City:HIALEAH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33018-4534
Practice Address - Country:US
Practice Address - Phone:305-680-9629
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-06
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FLSZ10463207ZP0213X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0213XAllopathic & Osteopathic PhysiciansPathologyPediatric Pathology
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104678700Medicaid