Healthcare Provider Details

I. General information

NPI: 1124076799
Provider Name (Legal Business Name): LYNNETTE M BURGOS LCDA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 08/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 AVE PONCE DE LEON SUITE 412
SAN JUAN PR
00909-1900
US

IV. Provider business mailing address

1801 AVE PONCE DE LEON SUITE 412
SAN JUAN PR
00909-1900
US

V. Phone/Fax

Practice location:
  • Phone: 787-726-0440
  • Fax: 787-727-5574
Mailing address:
  • Phone: 787-726-0440
  • Fax: 787-727-5574

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number1234
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: