Provider Demographics
NPI:1053085399
Name:RODRIGUEZ, NISSETTE M (LND, RDN)
Entity Type:Individual
Prefix:
First Name:NISSETTE
Middle Name:M
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:LND, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 450
Mailing Address - Street 2:
Mailing Address - City:ARROYO
Mailing Address - State:PR
Mailing Address - Zip Code:00714-0450
Mailing Address - Country:US
Mailing Address - Phone:787-839-4150
Mailing Address - Fax:
Practice Address - Street 1:STREET MORSE
Practice Address - Street 2:
Practice Address - City:ARROYO
Practice Address - State:PR
Practice Address - Zip Code:00714-0450
Practice Address - Country:US
Practice Address - Phone:787-839-4150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-02
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1920133N00000X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1920OtherLICENSE