Provider Demographics
NPI:1356120935
Name:RAICES DE JESUS, DEYANEIRA
Entity type:Individual
Prefix:
First Name:DEYANEIRA
Middle Name:
Last Name:RAICES DE JESUS
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:HC 1 BOX 5005
Mailing Address - Street 2:
Mailing Address - City:CAMUY
Mailing Address - State:PR
Mailing Address - Zip Code:00627-9194
Mailing Address - Country:US
Mailing Address - Phone:787-475-4410
Mailing Address - Fax:
Practice Address - Street 1:1046 AVE HOSTOS STE 118
Practice Address - Street 2:
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00716-1119
Practice Address - Country:US
Practice Address - Phone:787-841-3260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-25
Last Update Date:2023-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2876390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program