Provider Demographics
NPI:1679789945
Name:MORALES, WANDA (LND)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:MORALES
Suffix:
Gender:F
Credentials:LND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11202 COSTA ESMERALDA
Mailing Address - Street 2:
Mailing Address - City:CEIBA
Mailing Address - State:PR
Mailing Address - Zip Code:00735-3658
Mailing Address - Country:US
Mailing Address - Phone:787-435-6693
Mailing Address - Fax:787-656-0750
Practice Address - Street 1:AVE FONT MARTELO 355
Practice Address - Street 2:
Practice Address - City:HUMACAO
Practice Address - State:PR
Practice Address - Zip Code:00791
Practice Address - Country:US
Practice Address - Phone:787-852-0768
Practice Address - Fax:787-656-0750
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR801133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered