MEDICARE: CARLA FABIAN GONZALEZ LND, MHSCN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133N00000X	Nutritionist	1856	PR

General Provider Information

NPI Number	:	1568852341
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLA FABIAN GONZALEZ LND, MHSCN

Provider Business Mailing Address
First Line	:	6501 CARR 844 APT 202
Second Line	:
City	:	SAN JUAN
State	:	PR
Zip	:	00926-7824
Country	:	US
Telephone Number	:	787-224-7104
Fax Number	:

Provider Business Practice Location Address
First Line	:	1777 CARR 844
Second Line	:
City	:	SAN JUAN
State	:	PR
Zip	:	00926-4434
Country	:	US
Telephone Number	:	787-748-9955
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/30/2015
Last Update Date	:	01/30/2015

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