Provider Demographics
NPI:1457362410
Name:FARDALES, MARICELA DIANEXI (PA)
Entity type:Individual
Prefix:
First Name:MARICELA
Middle Name:DIANEXI
Last Name:FARDALES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8051 W 24TH AVE STE 9
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33016-5596
Mailing Address - Country:US
Mailing Address - Phone:305-400-9702
Mailing Address - Fax:305-735-7542
Practice Address - Street 1:8051 W 24TH AVE STE 9
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016-5596
Practice Address - Country:US
Practice Address - Phone:305-400-9702
Practice Address - Fax:305-735-7542
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103093363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004570500Medicaid
FL004570500Medicaid