Healthcare Provider Details

I. General information

NPI: 1194337444
Provider Name (Legal Business Name): ILEANA MARIA FIALLO MOREJON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2020
Last Update Date: 07/21/2022
Certification Date: 07/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 W PALM DR
FLORIDA CITY FL
33034-3223
US

IV. Provider business mailing address

6100 BLUE LAGOON DR STE 365
MIAMI FL
33126-7010
US

V. Phone/Fax

Practice location:
  • Phone: 786-377-0120
  • Fax: 305-248-6106
Mailing address:
  • Phone: 786-322-7333
  • Fax: 786-347-5022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11006584
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: