Provider Demographics
NPI:1770059982
Name:SOTOMAYOR CHACON, LUISA KATERINE
Entity type:Individual
Prefix:
First Name:LUISA
Middle Name:KATERINE
Last Name:SOTOMAYOR CHACON
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 1:7333 CANAL BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33615-5601
Mailing Address - Country:US
Mailing Address - Phone:623-742-8494
Mailing Address - Fax:
Practice Address - Street 1:7333 CANAL BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33615-5601
Practice Address - Country:US
Practice Address - Phone:623-742-8494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-16
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCNA304264376K00000X
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty
No376K00000XNursing Service Related ProvidersNurse's AideGroup - Multi-Specialty