Provider Demographics
NPI:1093806929
Name:SANTANA, MAYRA I
Entity Type:Individual
Prefix:
First Name:MAYRA
Middle Name:I
Last Name:SANTANA
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:CALLE 4 C 23
Mailing Address - Street 2:SANTA RITA
Mailing Address - City:VEGA ALTA
Mailing Address - State:PR
Mailing Address - Zip Code:00692
Mailing Address - Country:US
Mailing Address - Phone:787-376-8706
Mailing Address - Fax:
Practice Address - Street 1:196 CALLE JUAN P DUARTE
Practice Address - Street 2:FIRST FLOOR
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00917-3611
Practice Address - Country:US
Practice Address - Phone:787-759-6909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1028133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education