Provider Demographics
NPI:1477134518
Name:SILVA, WILDALIZ
Entity Type:Individual
Prefix:MISS
First Name:WILDALIZ
Middle Name:
Last Name:SILVA
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:WILDALIZ
Other - Middle Name:
Other - Last Name:SILVA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:6109 CARR 694
Mailing Address - Street 2:
Mailing Address - City:VEGA ALTA
Mailing Address - State:PR
Mailing Address - Zip Code:00692-9781
Mailing Address - Country:US
Mailing Address - Phone:787-270-0460
Mailing Address - Fax:
Practice Address - Street 1:CALLE 4 #29 PUESTA DEL SOL CERRO GORDO
Practice Address - Street 2:
Practice Address - City:VEGA ALTA
Practice Address - State:PR
Practice Address - Zip Code:00692
Practice Address - Country:US
Practice Address - Phone:787-904-0313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-20
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR13338183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1844711OtherNO TENGO PLAN