Provider Demographics
NPI:1629426291
Name:VILLANUEVA, RUTH A
Entity Type:Individual
Prefix:
First Name:RUTH
Middle Name:A
Last Name:VILLANUEVA
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 1:21725 HOFFMAN ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48082-2462
Mailing Address - Country:US
Mailing Address - Phone:928-304-2648
Mailing Address - Fax:
Practice Address - Street 1:21725 HOFFMAN ST
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48082-2462
Practice Address - Country:US
Practice Address - Phone:928-304-2648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-24
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA32162474247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other