Provider Demographics
NPI:1508271776
Name:MEDINA CASTRO, ANNIE (LICENCIADA)
Entity Type:Individual
Prefix:MISS
First Name:ANNIE
Middle Name:
Last Name:MEDINA CASTRO
Suffix:
Gender:F
Credentials:LICENCIADA
Other - Prefix:MISS
Other - First Name:ANNIE
Other - Middle Name:
Other - Last Name:MEDINA CASTRO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LICENCIADA
Mailing Address - Street 1:NUM 43 CALLE 9A BLOQ 23
Mailing Address - Street 2:
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00985-5414
Mailing Address - Country:US
Mailing Address - Phone:787-877-0794
Mailing Address - Fax:787-272-8796
Practice Address - Street 1:COND CENTRO PLZ
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00909-2110
Practice Address - Country:US
Practice Address - Phone:787-480-2783
Practice Address - Fax:787-274-8796
Is Sole Proprietor?:No
Enumeration Date:2014-06-26
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR938133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR400025Medicare PIN