Provider Demographics
NPI:1386225431
Name:OLIVE, ILEANA RODRIGUEZ
Entity Type:Individual
Prefix:
First Name:ILEANA RODRIGUEZ
Middle Name:
Last Name:OLIVE
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 1:11001 NW 7TH ST APT 103
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33172-3676
Mailing Address - Country:US
Mailing Address - Phone:786-357-9259
Mailing Address - Fax:
Practice Address - Street 1:23123 STATE ROAD 7 STE 360
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33428-5489
Practice Address - Country:US
Practice Address - Phone:561-420-8111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-20
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11012668363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner