MEDICARE: ADAEZE ILO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	287006	AZ
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	1075587	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	287006	OTHER	AZ	NURSING LICENSE

General Provider Information

NPI Number	:	1134524317
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ADAEZE ILO

Provider Business Mailing Address
First Line	:	4053 KYNDRA CIR
Second Line	:
City	:	RICHARDSON
State	:	TX
Zip	:	75082-2762
Country	:	US
Telephone Number	:	951-545-1482
Fax Number	:

Provider Business Practice Location Address
First Line	:	2 N CENTRAL AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85004-2322
Country	:	US
Telephone Number	:	951-545-1482
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/30/2014
Last Update Date	:	09/26/2025

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Directions to “ ADAEZE ILO ” Practice Location

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