Provider Demographics
NPI:1073675088
Name:VEGUILLA, IVELISSE
Entity Type:Individual
Prefix:
First Name:IVELISSE
Middle Name:
Last Name:VEGUILLA
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:PMB 169 BOX 2400
Mailing Address - Street 2:
Mailing Address - City:AIBONITO
Mailing Address - State:PR
Mailing Address - Zip Code:00705
Mailing Address - Country:US
Mailing Address - Phone:787-903-3776
Mailing Address - Fax:787-954-0517
Practice Address - Street 1:CARR 14 KM 51.8 INT
Practice Address - Street 2:BO ROBLES
Practice Address - City:AIBONITO
Practice Address - State:PR
Practice Address - Zip Code:00705
Practice Address - Country:US
Practice Address - Phone:787-903-3776
Practice Address - Fax:787-954-0517
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist