Provider Demographics
NPI:1043692346
Name:JORGE, LEISA
Entity Type:Individual
Prefix:
First Name:LEISA
Middle Name:
Last Name:JORGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 CALLE VISTA MAR
Mailing Address - Street 2:URB COCO BEACH
Mailing Address - City:RIO GRANDE
Mailing Address - State:PR
Mailing Address - Zip Code:00745
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:CALLE VISTA MAR 607 URB COCO BEACH
Practice Address - Street 2:
Practice Address - City:RIO GRANDE
Practice Address - State:PUERTO RICO
Practice Address - Zip Code:00745
Practice Address - Country:UM
Practice Address - Phone:787-549-1049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-23
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR36899163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR4809461Medicaid