Provider Demographics
NPI:1093479529
Name:ILCENCO, DANIELA (RN)
Entity Type:Individual
Prefix:
First Name:DANIELA
Middle Name:
Last Name:ILCENCO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 HOVEY ST APT 2
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01930-3658
Mailing Address - Country:US
Mailing Address - Phone:978-704-5934
Mailing Address - Fax:
Practice Address - Street 1:12 HOVEY ST APT 2
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:MA
Practice Address - Zip Code:01930-3658
Practice Address - Country:US
Practice Address - Phone:978-704-5934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-30
Last Update Date:2021-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2318246163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse