Healthcare Provider Details

I. General information

NPI: 1457704322
Provider Name (Legal Business Name): KEYDI NICOLE BETANCOURT GONZALEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2016
Last Update Date: 11/17/2021
Certification Date: 11/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARR. 941 SALIDA BO. JAGUAS CALLE SAN ANTONIO FINAL
GURABO PR
00778
US

IV. Provider business mailing address

PO BOX 1277
GURABO PR
00778-1277
US

V. Phone/Fax

Practice location:
  • Phone: 787-737-2311
  • Fax:
Mailing address:
  • Phone: 787-737-2311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number21435
License Number StatePR
# 3
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number21435
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: