Provider Demographics
NPI:1073150637
Name:GONZALEZ VELAZQUEZ, JOHANNIE (LCDA)
Entity Type:Individual
Prefix:
First Name:JOHANNIE
Middle Name:
Last Name:GONZALEZ VELAZQUEZ
Suffix:
Gender:F
Credentials:LCDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 2 BOX 11671
Mailing Address - Street 2:
Mailing Address - City:MOCA
Mailing Address - State:PR
Mailing Address - Zip Code:00676-8255
Mailing Address - Country:US
Mailing Address - Phone:787-617-7144
Mailing Address - Fax:787-658-7116
Practice Address - Street 1:536 AVE VICTORIA
Practice Address - Street 2:
Practice Address - City:AGUADILLA
Practice Address - State:PR
Practice Address - Zip Code:00603-4623
Practice Address - Country:US
Practice Address - Phone:787-658-6218
Practice Address - Fax:787-658-7116
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-03
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1471133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1471OtherNUTRITIONIST / DIETIST