Healthcare Provider Details

I. General information

NPI: 1710549431
Provider Name (Legal Business Name): MRS. KIERSTEN ILAOA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2019
Last Update Date: 04/23/2021
Certification Date: 04/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

765 ROUTE 70 E
MARLTON NJ
08053-2341
US

IV. Provider business mailing address

765 ROUTE 70 E
MARLTON NJ
08053-2341
US

V. Phone/Fax

Practice location:
  • Phone: 856-983-3900
  • Fax:
Mailing address:
  • Phone: 856-983-3900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number26NJ00952100
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: