Provider Demographics
NPI:1013331370
Name:ILUSTRE, DIEMMAI (RN)
Entity Type:Individual
Prefix:
First Name:DIEMMAI
Middle Name:
Last Name:ILUSTRE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3030 MIDDLETOWN RD APT 3G
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-5360
Mailing Address - Country:US
Mailing Address - Phone:832-630-3354
Mailing Address - Fax:
Practice Address - Street 1:1315 YORK AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-5304
Practice Address - Country:US
Practice Address - Phone:212-746-5789
Practice Address - Fax:212-746-8144
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-06
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY673155163WI0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WI0500XNursing Service ProvidersRegistered NurseInfusion Therapy