Provider Demographics
NPI:1841616927
Name:GONZALEZ OTER, WANDA
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:GONZALEZ OTER
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:AB26 CALLE 43
Mailing Address - Street 2:SANTA JUANITA
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00956-4755
Mailing Address - Country:US
Mailing Address - Phone:787-299-6001
Mailing Address - Fax:
Practice Address - Street 1:AB26 CALLE 43
Practice Address - Street 2:SANTA JUANITA
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00956-4755
Practice Address - Country:US
Practice Address - Phone:787-299-6001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-12
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1690133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist