Provider Demographics
NPI:1629696851
Name:QUINTANA CHAVEZ, YULIANELA
Entity type:Individual
Prefix:
First Name:YULIANELA
Middle Name:
Last Name:QUINTANA CHAVEZ
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 1:5401 SW 139TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-6049
Mailing Address - Country:US
Mailing Address - Phone:786-817-1384
Mailing Address - Fax:
Practice Address - Street 1:4180 SW 74TH CT STE 210
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-4443
Practice Address - Country:US
Practice Address - Phone:305-456-3632
Practice Address - Fax:786-332-2882
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-14
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-126293106S00000X
FLRN9648509163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL107229000Medicaid