Provider Demographics
NPI:1366055907
Name:LANDAETA, WILLMER
Entity type:Individual
Prefix:
First Name:WILLMER
Middle Name:
Last Name:LANDAETA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3431 SW CORNELL AVE
Mailing Address - Street 2:
Mailing Address - City:PALM CITY
Mailing Address - State:FL
Mailing Address - Zip Code:34990-3465
Mailing Address - Country:US
Mailing Address - Phone:917-686-0809
Mailing Address - Fax:
Practice Address - Street 1:3431 SW CORNELL AVE
Practice Address - Street 2:
Practice Address - City:PALM CITY
Practice Address - State:FL
Practice Address - Zip Code:34990-3465
Practice Address - Country:US
Practice Address - Phone:917-686-0809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-24
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA86643225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist