Provider Demographics
NPI:1164133039
Name:ILAVANDERA APRN LLC
Entity Type:Organization
Organization Name:ILAVANDERA APRN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:MR
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LAVANDERA RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:716-423-3042
Mailing Address - Street 1:11654 SW 142ND PL
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-8607
Mailing Address - Country:US
Mailing Address - Phone:716-423-3042
Mailing Address - Fax:
Practice Address - Street 1:11654 SW 142ND PL
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-8607
Practice Address - Country:US
Practice Address - Phone:716-423-3042
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-12
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLLICENSEOther11012290