Provider Demographics
NPI:1952694499
Name:AVILES, BRENDA IVELISSE
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:IVELISSE
Last Name:AVILES
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 1:940 CARR 123
Mailing Address - Street 2:
Mailing Address - City:UTUADO
Mailing Address - State:PR
Mailing Address - Zip Code:00641-3201
Mailing Address - Country:US
Mailing Address - Phone:787-894-0100
Mailing Address - Fax:787-894-9515
Practice Address - Street 1:940 CARR 123
Practice Address - Street 2:
Practice Address - City:UTUADO
Practice Address - State:PR
Practice Address - Zip Code:00641-3201
Practice Address - Country:US
Practice Address - Phone:787-894-0100
Practice Address - Fax:787-894-9515
Is Sole Proprietor?:No
Enumeration Date:2011-05-17
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4702183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist