Provider Demographics
NPI:1245255033
Name:VERSALLES, GLADYS (CNA)
Entity type:Individual
Prefix:MRS
First Name:GLADYS
Middle Name:
Last Name:VERSALLES
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:795 NW 95TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33150-1817
Mailing Address - Country:US
Mailing Address - Phone:305-864-8323
Mailing Address - Fax:305-377-4815
Practice Address - Street 1:7705 ABBOTT AVE
Practice Address - Street 2:305
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33141-2344
Practice Address - Country:US
Practice Address - Phone:305-864-8323
Practice Address - Fax:305-377-4815
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL13818374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide