Basic Information
| Provider Information | |||||||||
| NPI: | 1225788292 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANCHEZ OLIVARES | ||||||||
| FirstName: | SUSANA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1710 EVERGLADES BLVD N | ||||||||
| Address2: | |||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341205515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8323221197 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3720 19TH AVE SW | ||||||||
| Address2: | |||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341176142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3058156167 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2022 | ||||||||
| LastUpdateDate: | 03/24/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | BACB688998 | FL | Y |
ID Information
| ID | Type | State | Issuer | Description | 11209100 | 05 | FL | MEDICAID |