Provider Demographics
NPI:1013153659
Name:KEREZSI, ILEANA
Entity Type:Individual
Prefix:MRS
First Name:ILEANA
Middle Name:
Last Name:KEREZSI
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 1:3519 SE CORA DR
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-3332
Mailing Address - Country:US
Mailing Address - Phone:503-235-0852
Mailing Address - Fax:503-239-1888
Practice Address - Street 1:3519 SE CORA DR
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-3332
Practice Address - Country:US
Practice Address - Phone:503-235-0852
Practice Address - Fax:503-239-1888
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-04
Last Update Date:2009-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR572854311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR572854Medicaid