Provider Demographics
NPI:1275801615
Name:FUENTES, ILEANA
Entity Type:Individual
Prefix:MRS
First Name:ILEANA
Middle Name:
Last Name:FUENTES
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:MONTECARLOS SHOPPING CENTER LOCAL #1
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00924
Mailing Address - Country:US
Mailing Address - Phone:787-762-1616
Mailing Address - Fax:
Practice Address - Street 1:CENTRO COMERCIAL
Practice Address - Street 2:MONTERCARLO LOCAL #1
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00924-3554
Practice Address - Country:US
Practice Address - Phone:787-762-1616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-13
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR8141183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician