Provider Demographics
NPI:1568852341
Name:FABIAN GONZALEZ, CARLA (LND, MHSCN)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:
Last Name:FABIAN GONZALEZ
Suffix:
Gender:F
Credentials:LND, MHSCN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6501 CARR 844 APT 202
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-7824
Mailing Address - Country:US
Mailing Address - Phone:787-224-7104
Mailing Address - Fax:
Practice Address - Street 1:1777 CARR 844
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00926-4434
Practice Address - Country:US
Practice Address - Phone:787-748-9955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-30
Last Update Date:2015-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1856133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist