Provider Demographics
NPI:1427747617
Name:NODARSE CONSUEGRA, LISANDRA
Entity type:Individual
Prefix:
First Name:LISANDRA
Middle Name:
Last Name:NODARSE CONSUEGRA
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 1:823 E 31ST ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33013-3428
Mailing Address - Country:US
Mailing Address - Phone:305-216-5396
Mailing Address - Fax:
Practice Address - Street 1:823 E 31ST ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33013-3428
Practice Address - Country:US
Practice Address - Phone:305-216-5396
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-03
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QS1000X
FLDN28199122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health