Healthcare Provider Details

I. General information

NPI: 1639627946
Provider Name (Legal Business Name): ISAMARYS ACEVEDO GONZALEZ LND
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2016
Last Update Date: 09/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARR 493 KM 0.5 MEDICAL AND PROFESSIONAL OFFICE PLAZA SUITE 124
HATILLO PR
00659
US

IV. Provider business mailing address

HC 2 BOX 4757
SABANA HOYOS PR
00688-9535
US

V. Phone/Fax

Practice location:
  • Phone: 787-544-4777
  • Fax:
Mailing address:
  • Phone: 787-387-5655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number1982
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: