Provider Demographics
NPI:1134766223
Name:PERNUT, LUCEYDIS
Entity type:Individual
Prefix:
First Name:LUCEYDIS
Middle Name:
Last Name:PERNUT
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 1:948 RAVEN AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33166-3835
Mailing Address - Country:US
Mailing Address - Phone:786-333-4096
Mailing Address - Fax:
Practice Address - Street 1:3176 S UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33025-3002
Practice Address - Country:US
Practice Address - Phone:954-544-2617
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-08
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11004888363L00000X
FLAPRN11004888363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner