Provider Demographics
NPI:1518669621
Name:PERDOMO FUENTES, JOANNE MARIE
Entity Type:Individual
Prefix:MISS
First Name:JOANNE
Middle Name:MARIE
Last Name:PERDOMO FUENTES
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:RR 2 BOX 4049
Mailing Address - Street 2:
Mailing Address - City:TOA ALTA
Mailing Address - State:PR
Mailing Address - Zip Code:00953-7003
Mailing Address - Country:US
Mailing Address - Phone:787-365-3115
Mailing Address - Fax:
Practice Address - Street 1:2 AVE LOMAS VERDES # A2
Practice Address - Street 2:
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00956-3177
Practice Address - Country:US
Practice Address - Phone:787-365-3115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-21
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332BN1400X
PR174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
No174N00000XOther Service ProvidersLactation Consultant, Non-RN