Provider Demographics
NPI:1447071303
Name:DUQUE MEDERO, WILMARY
Entity type:Individual
Prefix:
First Name:WILMARY
Middle Name:
Last Name:DUQUE MEDERO
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 1:7866 W 34TH LN UNIT 201
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33018-5053
Mailing Address - Country:US
Mailing Address - Phone:786-973-9048
Mailing Address - Fax:
Practice Address - Street 1:7866 W 34TH LN UNIT 201
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33018-5053
Practice Address - Country:US
Practice Address - Phone:786-973-9048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-22
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-386866106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician