Provider Demographics
NPI:1801586326
Name:PONCE DE LEON ARENCIBIA, LISANDRA YADIRA
Entity type:Individual
Prefix:
First Name:LISANDRA
Middle Name:YADIRA
Last Name:PONCE DE LEON ARENCIBIA
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 1:20535 SW 122ND AVE APT 104
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33177-5693
Mailing Address - Country:US
Mailing Address - Phone:786-597-3869
Mailing Address - Fax:
Practice Address - Street 1:20535 SW 122ND AVE APT 104
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33177-5693
Practice Address - Country:US
Practice Address - Phone:786-597-3869
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-09
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11026216363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily