Provider Demographics
NPI:1275293128
Name:RALDIRIS, ISMARIE (RD, IBCLC)
Entity Type:Individual
Prefix:
First Name:ISMARIE
Middle Name:
Last Name:RALDIRIS
Suffix:
Gender:F
Credentials:RD, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 GRAND BLVD LOS PRADOS APT 6102
Mailing Address - Street 2:
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00727-3412
Mailing Address - Country:US
Mailing Address - Phone:787-633-8677
Mailing Address - Fax:
Practice Address - Street 1:500 GRAND BLVD LOS PRADOS APT 6102
Practice Address - Street 2:
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00727-3412
Practice Address - Country:US
Practice Address - Phone:787-633-8677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-20
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
L-86786174N00000X
PR1697133N00000X
1069646133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
No174N00000XOther Service ProvidersLactation Consultant, Non-RN
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered