Healthcare Provider Details

I. General information

NPI: 1255979696
Provider Name (Legal Business Name): MISS LEIRALY GAUTIER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2019
Last Update Date: 12/17/2019
Certification Date: 12/17/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HF16 CALLE LIZZIE GRAHAM # 7MA
TOA BAJA PR
00949-3634
US

IV. Provider business mailing address

URB ROYAL TOWN CALLE 6 D 6
BAYAMOM PR
00956
US

V. Phone/Fax

Practice location:
  • Phone: 787-795-2935
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number1478
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: