Provider Demographics
NPI:1033892864
Name:DE LA INCERA, JUDITH (PMHNP)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:
Last Name:DE LA INCERA
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6175 NW 153RD ST STE 404
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33014-2493
Mailing Address - Country:US
Mailing Address - Phone:305-558-7400
Mailing Address - Fax:305-558-6134
Practice Address - Street 1:423 SW 80TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33144-2121
Practice Address - Country:US
Practice Address - Phone:786-715-9022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-09
Last Update Date:2024-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11027992363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health