Provider Demographics
NPI:1740947118
Name:FUENTES SUJO, LAI (ARNP)
Entity type:Individual
Prefix:
First Name:LAI
Middle Name:
Last Name:FUENTES SUJO
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10102 WHEATLEY HILLS CT
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33615-2646
Mailing Address - Country:US
Mailing Address - Phone:813-863-2907
Mailing Address - Fax:
Practice Address - Street 1:10102 WHEATLEY HILLS CT
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33615-2646
Practice Address - Country:US
Practice Address - Phone:813-863-2907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-20
Last Update Date:2022-03-24
Deactivation Date:2021-11-20
Deactivation Code:
Reactivation Date:2022-03-24
Provider Licenses
StateLicense IDTaxonomies
FL11016194363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner