Provider Demographics
NPI:1477150357
Name:SANTIAGO AVILES, CRYSTALEE (LND)
Entity Type:Individual
Prefix:MISS
First Name:CRYSTALEE
Middle Name:
Last Name:SANTIAGO AVILES
Suffix:
Gender:F
Credentials:LND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 1 BOX 5709
Mailing Address - Street 2:
Mailing Address - City:BARRANQUITAS
Mailing Address - State:PR
Mailing Address - Zip Code:00794-9420
Mailing Address - Country:US
Mailing Address - Phone:787-516-6525
Mailing Address - Fax:
Practice Address - Street 1:URBANIZACION SAN DEMETRIO CALLE CASABE
Practice Address - Street 2:APARTAMENTO 102
Practice Address - City:VEGA BAJA
Practice Address - State:PR
Practice Address - Zip Code:00694
Practice Address - Country:US
Practice Address - Phone:787-516-6525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-05
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1676133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist