Provider Demographics
NPI:1619236296
Name:VALLEJO, LETICIA
Entity Type:Individual
Prefix:
First Name:LETICIA
Middle Name:
Last Name:VALLEJO
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 1:385 CALLE MANUEL DOMENECH
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00918-3718
Mailing Address - Country:US
Mailing Address - Phone:787-649-1928
Mailing Address - Fax:787-771-9715
Practice Address - Street 1:385 CALLE MANUEL DOMENECH
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918-3718
Practice Address - Country:US
Practice Address - Phone:787-649-1928
Practice Address - Fax:787-771-9715
Is Sole Proprietor?:No
Enumeration Date:2012-05-16
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2531163WW0000X
PR029473164W00000X
FLRN9217270164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WW0000XNursing Service ProvidersRegistered NurseWound Care
No164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR2531OtherC.W.S.