Provider Demographics
NPI:1407653413
Name:ACOSTA BRAVO, ILMARIELIANY
Entity type:Individual
Prefix:
First Name:ILMARIELIANY
Middle Name:
Last Name:ACOSTA BRAVO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 45TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-1189
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:645 S 20TH ST APT E24
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68510-2730
Practice Address - Country:US
Practice Address - Phone:978-764-5942
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-26
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC236Medicaid
5874OtherHEALTH PARTNERS
568946544OtherBCBS