MEDICARE: WENDELINE RULLAN VEGA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TS0200X	School Psychologist	3046	PR

General Provider Information

NPI Number	:	1134446222
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WENDELINE RULLAN VEGA

Provider Business Mailing Address
First Line	:	1157 CALLE CANADA
Second Line	:	PUERTO NUEVO
City	:	SAN JUAN
State	:	PR
Zip	:	00920-3828
Country	:	US
Telephone Number	:	787-510-4744
Fax Number	:

Provider Business Practice Location Address
First Line	:	1157 CALLE CANADA
Second Line	:	PUERTO NUEVO
City	:	SAN JUAN
State	:	PR
Zip	:	00920-3828
Country	:	US
Telephone Number	:	787-510-4744
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/28/2010
Last Update Date	:	04/28/2010

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