Provider Demographics
NPI:1952892234
Name:DE UNGRIA, MARIA KRISELDA GUEVARA
Entity Type:Individual
Prefix:
First Name:MARIA KRISELDA
Middle Name:GUEVARA
Last Name:DE UNGRIA
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 1:511 W COLLEGE BLVD APT A2
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-5122
Mailing Address - Country:US
Mailing Address - Phone:954-258-9825
Mailing Address - Fax:
Practice Address - Street 1:925 S SEMORAN BLVD
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-5313
Practice Address - Country:US
Practice Address - Phone:800-521-9604
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-23
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPT5187225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM515990526OtherDRIVERS LICENSE