Provider Demographics
NPI:1477673283
Name:COLLAZO, MARIBEL
Entity Type:Individual
Prefix:MRS
First Name:MARIBEL
Middle Name:
Last Name:COLLAZO
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 1:473 CALLE BAYAMON
Mailing Address - Street 2:LA CUMBRE
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-5558
Mailing Address - Country:US
Mailing Address - Phone:787-922-7053
Mailing Address - Fax:787-703-1646
Practice Address - Street 1:CALLE SERGIO CUEVAS BUSTAMANTE 550
Practice Address - Street 2:
Practice Address - City:HATO REY
Practice Address - State:PR
Practice Address - Zip Code:00918
Practice Address - Country:US
Practice Address - Phone:787-758-8383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1298133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist