Provider Demographics
NPI:1629664685
Name:FONTANEZ VENDRELL, ITCHAQUEIRA BEATRIZ (RD/LDN)
Entity Type:Individual
Prefix:
First Name:ITCHAQUEIRA
Middle Name:BEATRIZ
Last Name:FONTANEZ VENDRELL
Suffix:
Gender:F
Credentials:RD/LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1675 POLO LAKE DR E APT 104
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-3112
Mailing Address - Country:US
Mailing Address - Phone:863-258-7986
Mailing Address - Fax:
Practice Address - Street 1:1675 POLO LAKE DR E APT 104
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-3112
Practice Address - Country:US
Practice Address - Phone:863-258-7986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-14
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 133N00000X, 133NN1002X, 171W00000X
FL9854133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No171W00000XOther Service ProvidersContractor