Provider Demographics
NPI:1124559323
Name:MARIN, IVELISA
Entity Type:Individual
Prefix:
First Name:IVELISA
Middle Name:
Last Name:MARIN
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:URB. BORINQUEN VALLEY C/ MARTILLO 219
Mailing Address - Street 2:
Mailing Address - City:CAGUAS
Mailing Address - State:PUERTO RICO
Mailing Address - Zip Code:00725
Mailing Address - Country:UM
Mailing Address - Phone:787-605-3510
Mailing Address - Fax:787-727-5561
Practice Address - Street 1:28 CALLE 2
Practice Address - Street 2:AVENIDA BAIROA
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00000-0725
Practice Address - Country:US
Practice Address - Phone:787-605-3510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-21
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1454133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist