Provider Demographics
NPI:1891360152
Name:NOLASCO, IVELISSE
Entity Type:Individual
Prefix:
First Name:IVELISSE
Middle Name:
Last Name:NOLASCO
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 1:7232 PARK HEIGHTS AVE APT B
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21208-5426
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7232 PARK HEIGHTS AVE APT B
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21208-5426
Practice Address - Country:US
Practice Address - Phone:347-421-5897
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-20
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker