Provider Demographics
NPI:1235331745
Name:DIAZ BOULON, ALICIA Z (LND, RD, MHSN, CDE)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:Z
Last Name:DIAZ BOULON
Suffix:
Gender:F
Credentials:LND, RD, MHSN, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:LA ALAMEDA
Mailing Address - Street 2:785 CALLE RUBI
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-6733
Mailing Address - Country:US
Mailing Address - Phone:787-422-0202
Mailing Address - Fax:
Practice Address - Street 1:LA ALAMEDA
Practice Address - Street 2:785 CALLE RUBI
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00926-6733
Practice Address - Country:US
Practice Address - Phone:787-422-0202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-05
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1239133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR867067OtherRD
PR1239OtherLND
PR2062-0127OtherCERT. DIABETES EDUCATOR