Provider Demographics
NPI:1598513616
Name:MATIENZO, ILIANA C
Entity type:Individual
Prefix:
First Name:ILIANA
Middle Name:C
Last Name:MATIENZO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:526 78TH ST
Mailing Address - Street 2:
Mailing Address - City:NORTH BERGEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07047-4927
Mailing Address - Country:US
Mailing Address - Phone:551-482-9205
Mailing Address - Fax:
Practice Address - Street 1:526 78TH ST
Practice Address - Street 2:
Practice Address - City:NORTH BERGEN
Practice Address - State:NJ
Practice Address - Zip Code:07047-4927
Practice Address - Country:US
Practice Address - Phone:551-482-9205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-13
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program