Healthcare Provider Details

I. General information

NPI: 1619236296
Provider Name (Legal Business Name): LETICIA VALLEJO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2012
Last Update Date: 09/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

385 CALLE MANUEL DOMENECH
SAN JUAN PR
00918-3718
US

IV. Provider business mailing address

385 CALLE MANUEL DOMENECH
SAN JUAN PR
00918-3718
US

V. Phone/Fax

Practice location:
  • Phone: 787-649-1928
  • Fax: 787-771-9715
Mailing address:
  • Phone: 787-649-1928
  • Fax: 787-771-9715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number2531
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number029473
License Number StatePR
# 3
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberRN9217270
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: