Healthcare Provider Details

I. General information

NPI: 1386364461
Provider Name (Legal Business Name): MARANGELIS FUENTES EMMANUELLI PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2022
Last Update Date: 08/30/2022
Certification Date: 08/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

E6 CALLE SANTA CRUZ
BAYAMON PR
00961
US

IV. Provider business mailing address

469 AVE ESMERALDA APT 252
GUAYNABO PR
00969-4287
US

V. Phone/Fax

Practice location:
  • Phone: 787-330-2100
  • Fax:
Mailing address:
  • Phone: 787-233-4505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number4650
License Number StatePR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier4620
Identifier TypeMEDICAID
Identifier StatePR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: