Provider Demographics
NPI:1477061448
Name:ILLARRETA PENA, LUISA MARIA (APRN)
Entity Type:Individual
Prefix:
First Name:LUISA
Middle Name:MARIA
Last Name:ILLARRETA PENA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9375 FONTAINEBLEAU BLVD APT L112
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33172-5650
Mailing Address - Country:US
Mailing Address - Phone:786-398-2923
Mailing Address - Fax:
Practice Address - Street 1:9375 FONTAINEBLEAU BLVD APT L112
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33172-5650
Practice Address - Country:US
Practice Address - Phone:786-398-2923
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-12
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11023885363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily