Provider Demographics
NPI:1952823379
Name:CAMEJO LEONOR, MALLIANY
Entity Type:Individual
Prefix:
First Name:MALLIANY
Middle Name:
Last Name:CAMEJO LEONOR
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 919771
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-9771
Mailing Address - Country:US
Mailing Address - Phone:239-278-3600
Mailing Address - Fax:
Practice Address - Street 1:11921 SARADRIENNE LN
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34135-5911
Practice Address - Country:US
Practice Address - Phone:393-442-3532
Practice Address - Fax:239-992-4984
Is Sole Proprietor?:No
Enumeration Date:2017-07-07
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME145242208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMN964OtherMEDICARE
FL106651300Medicaid