Provider Demographics
NPI:1942808977
Name:ILIAZI, ETLEVA
Entity Type:Individual
Prefix:
First Name:ETLEVA
Middle Name:
Last Name:ILIAZI
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 1:8722 BELLE RIVE BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-8452
Mailing Address - Country:US
Mailing Address - Phone:904-382-5238
Mailing Address - Fax:
Practice Address - Street 1:13241 BARTRAM PARK BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-5212
Practice Address - Country:US
Practice Address - Phone:904-288-6910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-12
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11003397363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily