Provider Demographics
NPI:1750868634
Name:AQUINO, MAYRA
Entity type:Individual
Prefix:
First Name:MAYRA
Middle Name:
Last Name:AQUINO
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 1:11610 GLADEFIELD DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77099-2638
Mailing Address - Country:US
Mailing Address - Phone:832-277-8478
Mailing Address - Fax:
Practice Address - Street 1:7457 HARWIN DR STE 324
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77036-2022
Practice Address - Country:US
Practice Address - Phone:713-274-8505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-24
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT84494133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXDT84494Medicaid