Provider Demographics
NPI:1750682183
Name:FONTANEZ, IVELISSE (MSN)
Entity Type:Individual
Prefix:
First Name:IVELISSE
Middle Name:
Last Name:FONTANEZ
Suffix:
Gender:F
Credentials:MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3382
Mailing Address - Street 2:
Mailing Address - City:RIO GRANDE
Mailing Address - State:PR
Mailing Address - Zip Code:00745-3382
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:CALLE 5 D-19 ESTANCIAS DEL MADRIGAL
Practice Address - Street 2:
Practice Address - City:RIO GRANDE
Practice Address - State:PR
Practice Address - Zip Code:00745
Practice Address - Country:US
Practice Address - Phone:787-596-5144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-17
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR31455163WG0600X, 163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0600XNursing Service ProvidersRegistered NurseGerontology
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health