Provider Demographics
NPI:1992239271
Name:NAVEDO-DISTAFFEN, MAYRA (ARNP-C)
Entity type:Individual
Prefix:
First Name:MAYRA
Middle Name:
Last Name:NAVEDO-DISTAFFEN
Suffix:
Gender:F
Credentials:ARNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 386
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-0386
Mailing Address - Country:US
Mailing Address - Phone:352-404-5968
Mailing Address - Fax:
Practice Address - Street 1:3121 CITRUS TOWER BLVD
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-6881
Practice Address - Country:US
Practice Address - Phone:352-404-5968
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-13
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9288357363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health