Provider Demographics
NPI:1639715741
Name:SUAZO, INGRID
Entity type:Individual
Prefix:
First Name:INGRID
Middle Name:
Last Name:SUAZO
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 1:14615 CRESCENT ROCK DR
Mailing Address - Street 2:
Mailing Address - City:WIMAUMA
Mailing Address - State:FL
Mailing Address - Zip Code:33598-6186
Mailing Address - Country:US
Mailing Address - Phone:813-453-0028
Mailing Address - Fax:205-961-5119
Practice Address - Street 1:14615 CRESCENT ROCK DR
Practice Address - Street 2:
Practice Address - City:WIMAUMA
Practice Address - State:FL
Practice Address - Zip Code:33598-6186
Practice Address - Country:US
Practice Address - Phone:813-898-3536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-24
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11024608363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty