Provider Demographics
NPI:1831800218
Name:MOGENA PADRON, YUDAISY (CBHCMS)
Entity type:Individual
Prefix:MRS
First Name:YUDAISY
Middle Name:
Last Name:MOGENA PADRON
Suffix:
Gender:F
Credentials:CBHCMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1539 DALE MABRY HWY STE 102
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33548-3008
Mailing Address - Country:US
Mailing Address - Phone:813-909-7102
Mailing Address - Fax:813-909-0199
Practice Address - Street 1:1539 DALE MABRY HWY STE 102
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33548-3008
Practice Address - Country:US
Practice Address - Phone:813-909-7102
Practice Address - Fax:813-909-0199
Is Sole Proprietor?:No
Enumeration Date:2022-12-07
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0105383171M00000X
PR2295PA363A00000X
FLTPPA830363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCBHCM0105383OtherFLORIDA CERTIFICATION BOARD
FL116404300Medicaid
PR2295PAOtherPUERTO RICO MEDICAL DISCIPLINE AND LICENSUREE BOARD
FLTPPA830OtherFLORIDA DEPARTMENT OF HEALTH
FLCBHCMS0102580OtherFLORIDA CERTIFICATION BOARD