Provider Demographics
NPI:1942995154
Name:IRIZARRY-CASTILLO, IDALIA (MHSN, LND, RDN)
Entity Type:Individual
Prefix:
First Name:IDALIA
Middle Name:
Last Name:IRIZARRY-CASTILLO
Suffix:
Gender:F
Credentials:MHSN, LND, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 1 BOX 6100
Mailing Address - Street 2:
Mailing Address - City:GUAYANILLA
Mailing Address - State:PR
Mailing Address - Zip Code:00656-9444
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:351 AVE HOSTOS STE 205
Practice Address - Street 2:
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00680-1503
Practice Address - Country:US
Practice Address - Phone:787-831-5831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-05
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86071726133V00000X
PR2169133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered