Healthcare Provider Details

I. General information

NPI: 1750682183
Provider Name (Legal Business Name): IVELISSE FONTANEZ MSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2010
Last Update Date: 11/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CALLE 5 D-19 ESTANCIAS DEL MADRIGAL
RIO GRANDE PR
00745
US

IV. Provider business mailing address

PO BOX 3382
RIO GRANDE PR
00745-3382
US

V. Phone/Fax

Practice location:
  • Phone: 787-596-5144
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0600X
TaxonomyGerontology Registered Nurse
License Number31455
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number31455
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: