Provider Demographics
NPI:1427611045
Name:SEPULVEDA HUERTA, MIDDER (APRN)
Entity type:Individual
Prefix:
First Name:MIDDER
Middle Name:
Last Name:SEPULVEDA HUERTA
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3448 W 14TH LN
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-4722
Mailing Address - Country:US
Mailing Address - Phone:786-715-9264
Mailing Address - Fax:
Practice Address - Street 1:3448 W 14TH LN
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-4722
Practice Address - Country:US
Practice Address - Phone:786-715-9264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-18
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11000405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner