Healthcare Provider Details

I. General information

NPI: 1568657898
Provider Name (Legal Business Name): WALDESTRUDIS MADERA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2007
Last Update Date: 09/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARR. 14, TERRENOS SAN LUCAS II
PONCE PR
00732
US

IV. Provider business mailing address

HC 2 BOX 5437
PENUELAS PR
00624-9694
US

V. Phone/Fax

Practice location:
  • Phone: 787-840-6835
  • Fax:
Mailing address:
  • Phone: 787-836-5483
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberA004264
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: