Basic Information
| Provider Information | |||||||||
| NPI: | 1437893757 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LALUZ | ||||||||
| FirstName: | MARIELA | ||||||||
| MiddleName: | |||||||||
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| Credential: | ACNPC-AG | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2147 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339022147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3934399602 | ||||||||
| FaxNumber: | 2393439977 | ||||||||
| Practice Location | |||||||||
| Address1: | 8380 RIVERWALK PARK BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339198758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393439960 | ||||||||
| FaxNumber: | 2393439977 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2022 | ||||||||
| LastUpdateDate: | 06/15/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | APRN11019808 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363LA2100X | RN9402121 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 114332900 | 05 | FL | MEDICAID |