Healthcare Provider Details

I. General information

NPI: 1457979494
Provider Name (Legal Business Name): ILIANNA POLATOS-QUINTERO RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2020
Last Update Date: 07/07/2020
Certification Date: 07/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17902 NW 81ST CT
HIALEAH FL
33015-2847
US

IV. Provider business mailing address

5645 CORAL RIDGE DR # 107
CORAL SPRINGS FL
33076-3124
US

V. Phone/Fax

Practice location:
  • Phone: 954-815-9973
  • Fax:
Mailing address:
  • Phone: 954-815-9973
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number3293252
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: