Provider Demographics
NPI:1952830895
Name:LIZANO, MAGDA JOSEFINA
Entity Type:Individual
Prefix:
First Name:MAGDA
Middle Name:JOSEFINA
Last Name:LIZANO
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 1:1032 SILKTREE LN
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33327-2048
Mailing Address - Country:US
Mailing Address - Phone:754-801-9170
Mailing Address - Fax:
Practice Address - Street 1:10650 W STATE ROAD 84 STE 206
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33324-4235
Practice Address - Country:US
Practice Address - Phone:954-634-3636
Practice Address - Fax:954-634-3637
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-05
Last Update Date:2017-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021009500Medicaid