Provider Demographics
NPI:1881447837
Name:VALLEJO TAGLE, GENESIS MAYENNCY
Entity type:Individual
Prefix:
First Name:GENESIS
Middle Name:MAYENNCY
Last Name:VALLEJO TAGLE
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:PO BOX 5026
Mailing Address - Street 2:
Mailing Address - City:SAN SEBASTIAN
Mailing Address - State:PR
Mailing Address - Zip Code:00685-5026
Mailing Address - Country:US
Mailing Address - Phone:939-599-2274
Mailing Address - Fax:
Practice Address - Street 1:VA CARIBBEAN HEALTHCARE SYSTEM
Practice Address - Street 2:PSYCHOLOGY (116B), 10 CALLE CASIA
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00921
Practice Address - Country:US
Practice Address - Phone:939-599-2274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-09
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program