Provider Demographics
NPI:1043792567
Name:DE LA FUENTE, IVANNA
Entity Type:Individual
Prefix:
First Name:IVANNA
Middle Name:
Last Name:DE LA FUENTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 E ELIZABETH ST
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78520-5457
Mailing Address - Country:US
Mailing Address - Phone:956-545-5379
Mailing Address - Fax:
Practice Address - Street 1:4430 E 14TH ST UNIT E
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78521-3364
Practice Address - Country:US
Practice Address - Phone:956-542-6296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-30
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant