Provider Demographics
NPI:1265919682
Name:GUTIERREZ, ILIANA
Entity type:Individual
Prefix:
First Name:ILIANA
Middle Name:
Last Name:GUTIERREZ
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 1:16314 WILLETS POINT BLVD
Mailing Address - Street 2:
Mailing Address - City:WHITESTONE
Mailing Address - State:NY
Mailing Address - Zip Code:11357-3344
Mailing Address - Country:US
Mailing Address - Phone:718-986-8449
Mailing Address - Fax:
Practice Address - Street 1:16314 WILLETS POINT BLVD
Practice Address - Street 2:
Practice Address - City:WHITESTONE
Practice Address - State:NY
Practice Address - Zip Code:11357-3344
Practice Address - Country:US
Practice Address - Phone:718-986-8449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-27
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist