Provider Demographics
NPI:1255172037
Name:DE JESUS CARABALLO, ADA
Entity type:Individual
Prefix:
First Name:ADA
Middle Name:
Last Name:DE JESUS CARABALLO
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 1:752 36TH AVE S
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33705-3744
Mailing Address - Country:US
Mailing Address - Phone:727-201-7856
Mailing Address - Fax:
Practice Address - Street 1:752 36TH AVE S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33705-3744
Practice Address - Country:US
Practice Address - Phone:727-201-7856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-04
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator