Healthcare Provider Details

I. General information

NPI: 1740065044
Provider Name (Legal Business Name): ILNISE MATHIEU
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2023
Last Update Date: 08/28/2023
Certification Date: 08/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19621 NW 11TH CT
MIAMI FL
33169-3036
US

IV. Provider business mailing address

19621 NW 11TH CT
MIAMI FL
33169-3036
US

V. Phone/Fax

Practice location:
  • Phone: 786-731-5147
  • Fax:
Mailing address:
  • Phone: 786-731-5147
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: