Provider Demographics
NPI:1043649916
Name:REVOREDO, MARIA
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:REVOREDO
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 1:15973 SW 13TH ST
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33027-5053
Mailing Address - Country:US
Mailing Address - Phone:305-467-2255
Mailing Address - Fax:
Practice Address - Street 1:1040 CARIBBEAN WAY
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33132
Practice Address - Country:US
Practice Address - Phone:786-398-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-01
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3027452363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily