Provider Demographics
NPI:1821351636
Name:MEDINA GARCIA, ONELLYS M (LND)
Entity Type:Individual
Prefix:
First Name:ONELLYS
Middle Name:M
Last Name:MEDINA GARCIA
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 1:1551 CALLE MARTIN TRAVIESO APT 1
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00911-1940
Mailing Address - Country:US
Mailing Address - Phone:787-531-1036
Mailing Address - Fax:
Practice Address - Street 1:CARR 110 KM 0 3
Practice Address - Street 2:BO CEIBA BAJA
Practice Address - City:AGUADILLA
Practice Address - State:PR
Practice Address - Zip Code:00604
Practice Address - Country:US
Practice Address - Phone:787-531-1036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-18
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1646133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1646OtherLICENSE