Provider Demographics
NPI:1710044722
Name:ROMAN, IVELISSE
Entity Type:Individual
Prefix:MISS
First Name:IVELISSE
Middle Name:
Last Name:ROMAN
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 1:835 CALLE CONCEPCION VERA
Mailing Address - Street 2:
Mailing Address - City:MOCA
Mailing Address - State:PR
Mailing Address - Zip Code:00676-5016
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:835 CALLE CONCEPCION VERA
Practice Address - Street 2:
Practice Address - City:MOCA
Practice Address - State:PR
Practice Address - Zip Code:00676-5016
Practice Address - Country:US
Practice Address - Phone:787-818-4839
Practice Address - Fax:787-877-8129
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4961183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician