Provider Demographics
NPI:1376001081
Name:RODRIGUEZ, IVELISSE
Entity Type:Individual
Prefix:
First Name:IVELISSE
Middle Name:
Last Name:RODRIGUEZ
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 1:212 WILLOW VALLEY LAKES DR
Mailing Address - Street 2:
Mailing Address - City:WILLOW STREET
Mailing Address - State:PA
Mailing Address - Zip Code:17584-9668
Mailing Address - Country:US
Mailing Address - Phone:717-224-5819
Mailing Address - Fax:
Practice Address - Street 1:212 WILLOW VALLEY LAKES DR
Practice Address - Street 2:
Practice Address - City:WILLOW STREET
Practice Address - State:PA
Practice Address - Zip Code:17584-9668
Practice Address - Country:US
Practice Address - Phone:717-224-5819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-12
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPN286931164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPN286931OtherLPN