Healthcare Provider Details

I. General information

NPI: 1619407236
Provider Name (Legal Business Name): ILEANA BERRIOS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2017
Last Update Date: 10/24/2023
Certification Date: 10/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4020 M ST
PHILADELPHIA PA
19124-5326
US

IV. Provider business mailing address

4020 M ST
PHILADELPHIA PA
19124-5326
US

V. Phone/Fax

Practice location:
  • Phone: 267-800-8090
  • Fax:
Mailing address:
  • Phone: 267-800-8090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: