Provider Demographics
NPI:1841711652
Name:DIAZ PORTUONDO, MAINEVIS BARBARA
Entity type:Individual
Prefix:
First Name:MAINEVIS
Middle Name:BARBARA
Last Name:DIAZ PORTUONDO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 W 76TH ST STE 411
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33016-5504
Mailing Address - Country:US
Mailing Address - Phone:786-655-9992
Mailing Address - Fax:
Practice Address - Street 1:14710 SW 110TH TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33196-3305
Practice Address - Country:US
Practice Address - Phone:786-395-7153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-30
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FLAPRN11010172363LF0000X
FLRN9483647363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician