Provider Demographics
NPI:1336711746
Name:OCAMPO QUESADA, IMARA C
Entity Type:Individual
Prefix:
First Name:IMARA
Middle Name:C
Last Name:OCAMPO QUESADA
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 1:10921 SW 42ND ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33165-4707
Mailing Address - Country:US
Mailing Address - Phone:786-260-9206
Mailing Address - Fax:
Practice Address - Street 1:10921 SW 42ND ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-4707
Practice Address - Country:US
Practice Address - Phone:786-260-9206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-14
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
FLAPRN11023436363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL108622600Medicaid