Provider Demographics
NPI:1740736412
Name:CRUZ, ILCA JEANNETE (LND)
Entity Type:Individual
Prefix:MRS
First Name:ILCA
Middle Name:JEANNETE
Last Name:CRUZ
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:B13 CALLE 22
Mailing Address - Street 2:MIRADOR UNIVERSITARIO
Mailing Address - City:CAYEY
Mailing Address - State:PR
Mailing Address - Zip Code:00736
Mailing Address - Country:US
Mailing Address - Phone:787-616-9858
Mailing Address - Fax:
Practice Address - Street 1:B13 CALLE 22
Practice Address - Street 2:MIRADOR UNIVERSITARIO
Practice Address - City:CAYEY
Practice Address - State:PR
Practice Address - Zip Code:00736-5077
Practice Address - Country:US
Practice Address - Phone:787-616-9858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-31
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1290133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered