Provider Demographics
NPI:1912775123
Name:LEYVA, LIDICE
Entity type:Individual
Prefix:
First Name:LIDICE
Middle Name:
Last Name:LEYVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LIDICE
Other - Middle Name:
Other - Last Name:ZAMORA DIAZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:154 MONTEREY WAY
Mailing Address - Street 2:
Mailing Address - City:ROYAL PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33411-7801
Mailing Address - Country:US
Mailing Address - Phone:561-248-9446
Mailing Address - Fax:
Practice Address - Street 1:154 MONTEREY WAY
Practice Address - Street 2:
Practice Address - City:ROYAL PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33411-7801
Practice Address - Country:US
Practice Address - Phone:561-248-9446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-18
Last Update Date:2024-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11030027363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner