Provider Demographics
NPI:1336871532
Name:REVELO, ILIANA (HHA)
Entity Type:Individual
Prefix:
First Name:ILIANA
Middle Name:
Last Name:REVELO
Suffix:
Gender:F
Credentials:HHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:627 NEWTON PL NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20010-1711
Mailing Address - Country:US
Mailing Address - Phone:202-808-2365
Mailing Address - Fax:
Practice Address - Street 1:TIERNO HOME SUPPORT AGENCY
Practice Address - Street 2:1752 COLUMBIA ROAD
Practice Address - City:WASHINGTON DC
Practice Address - State:DC
Practice Address - Zip Code:20009
Practice Address - Country:US
Practice Address - Phone:202-808-2365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-27
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA200001234374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC3497503OtherDRIVER LICENSE NUMBER