Provider Demographics
NPI:1770239402
Name:TRUJILLO, NIZAIDY
Entity type:Individual
Prefix:
First Name:NIZAIDY
Middle Name:
Last Name:TRUJILLO
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 1:814 E 126TH AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-4405
Mailing Address - Country:US
Mailing Address - Phone:832-231-0348
Mailing Address - Fax:
Practice Address - Street 1:2615 NATURE WALK APT 306
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33543-3757
Practice Address - Country:US
Practice Address - Phone:832-231-0348
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-22
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X
FL24-388686106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No251B00000XAgenciesCase Management