Provider Demographics
NPI:1780044081
Name:IZAGUIRRE, IVELISSE KELLY
Entity Type:Individual
Prefix:DR
First Name:IVELISSE
Middle Name:KELLY
Last Name:IZAGUIRRE
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 1:1775 GRAND CONCOURSE FL 6
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10453-8202
Mailing Address - Country:US
Mailing Address - Phone:718-901-8110
Mailing Address - Fax:718-901-8162
Practice Address - Street 1:1775 GRAND CONCOURSE FL 6
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10453-8202
Practice Address - Country:US
Practice Address - Phone:718-901-8110
Practice Address - Fax:718-901-8162
Is Sole Proprietor?:No
Enumeration Date:2016-02-29
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program