Provider Demographics
NPI:1619599206
Name:IBARRA, MARICELA
Entity Type:Individual
Prefix:
First Name:MARICELA
Middle Name:
Last Name:IBARRA
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 1:111 N COUNTY FARM RD
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-3988
Mailing Address - Country:US
Mailing Address - Phone:630-221-4739
Mailing Address - Fax:630-510-5464
Practice Address - Street 1:1111 W LAKE ST
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:IL
Practice Address - Zip Code:60101-1101
Practice Address - Country:US
Practice Address - Phone:630-221-4739
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-18
Last Update Date:2020-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL17100725172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker