Provider Demographics
NPI:1760989081
Name:DE LA LLANA, NIEVES
Entity Type:Individual
Prefix:
First Name:NIEVES
Middle Name:
Last Name:DE LA LLANA
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 1:709 BRIGGS ST APT 2
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33405-2597
Mailing Address - Country:US
Mailing Address - Phone:561-951-8256
Mailing Address - Fax:
Practice Address - Street 1:6415 LAKE WORTH RD STE 204
Practice Address - Street 2:
Practice Address - City:GREENACRES
Practice Address - State:FL
Practice Address - Zip Code:33463-2904
Practice Address - Country:US
Practice Address - Phone:617-719-5615
Practice Address - Fax:800-766-3139
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-12
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-18-68251106S00000X
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103032500Medicaid