Provider Demographics
NPI:1720281884
Name:FELICIANO, ILEANA (ETC)
Entity Type:Individual
Prefix:PROF
First Name:ILEANA
Middle Name:
Last Name:FELICIANO
Suffix:
Gender:F
Credentials:ETC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 292
Mailing Address - Street 2:
Mailing Address - City:BARCELONETA
Mailing Address - State:PR
Mailing Address - Zip Code:00617-0292
Mailing Address - Country:US
Mailing Address - Phone:787-884-6572
Mailing Address - Fax:
Practice Address - Street 1:MARGINAL ELLIOT VELEZ B 47
Practice Address - Street 2:
Practice Address - City:MANATI
Practice Address - State:PR
Practice Address - Zip Code:00674
Practice Address - Country:US
Practice Address - Phone:787-884-6572
Practice Address - Fax:787-884-6572
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1377133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRQ53050Medicare ID - Type Unspecified