Healthcare Provider Details

I. General information

NPI: 1568852341
Provider Name (Legal Business Name): CARLA FABIAN GONZALEZ LND, MHSCN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2015
Last Update Date: 01/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1777 CARR 844
SAN JUAN PR
00926-4434
US

IV. Provider business mailing address

6501 CARR 844 APT 202
SAN JUAN PR
00926-7824
US

V. Phone/Fax

Practice location:
  • Phone: 787-748-9955
  • Fax:
Mailing address:
  • Phone: 787-224-7104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number1856
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: