Provider Demographics
NPI:1174026348
Name:BALLESTEROS MOYANO, NELA F (MD)
Entity type:Individual
Prefix:DR
First Name:NELA
Middle Name:F
Last Name:BALLESTEROS MOYANO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 LAKE EMMA COVE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-2508
Mailing Address - Country:US
Mailing Address - Phone:407-310-3102
Mailing Address - Fax:
Practice Address - Street 1:107 LAKE EMMA COVE DR
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-2508
Practice Address - Country:US
Practice Address - Phone:407-310-3102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-14
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLACN11842083P0901X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Multi-Specialty