Provider Demographics
NPI:1457979494
Name:POLATOS-QUINTERO, ILIANNA (RN)
Entity Type:Individual
Prefix:
First Name:ILIANNA
Middle Name:
Last Name:POLATOS-QUINTERO
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 1:5645 CORAL RIDGE DR # 107
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33076-3124
Mailing Address - Country:US
Mailing Address - Phone:954-815-9973
Mailing Address - Fax:
Practice Address - Street 1:17902 NW 81ST CT
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33015-2847
Practice Address - Country:US
Practice Address - Phone:954-815-9973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-07
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3293252163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL677953196Medicaid