Provider Demographics
NPI:1639397037
Name:FUENTES, LIZ REBECA (ATOL)
Entity Type:Individual
Prefix:MRS
First Name:LIZ
Middle Name:REBECA
Last Name:FUENTES
Suffix:
Gender:F
Credentials:ATOL
Other - Prefix:MRS
Other - First Name:LIZ
Other - Middle Name:REBECA
Other - Last Name:FUENTES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATOL
Mailing Address - Street 1:CALLE 4 C-1
Mailing Address - Street 2:JARDINES DE FAGOT
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00716
Mailing Address - Country:US
Mailing Address - Phone:787-607-3797
Mailing Address - Fax:
Practice Address - Street 1:CALLE 4 C-1
Practice Address - Street 2:JARDINES DE FAGOT
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00716
Practice Address - Country:US
Practice Address - Phone:787-607-3797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR458174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist