Provider Demographics
NPI:1417769803
Name:BALLEZA, ALFONSO ALLAN M II
Entity type:Individual
Prefix:MR
First Name:ALFONSO ALLAN
Middle Name:M
Last Name:BALLEZA
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1480 RENAISSANCE DR STE 211
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-1353
Mailing Address - Country:US
Mailing Address - Phone:847-296-6161
Mailing Address - Fax:847-296-6262
Practice Address - Street 1:1480 RENAISSANCE DR STE 211
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1353
Practice Address - Country:US
Practice Address - Phone:847-296-6161
Practice Address - Fax:847-296-6262
Is Sole Proprietor?:No
Enumeration Date:2025-01-22
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041388781163WW0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WW0000XNursing Service ProvidersRegistered NurseWound Care