Basic Information
| Provider Information | |||||||||
| NPI: | 1154523017 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GONZALEZ | ||||||||
| FirstName: | MARIBEL | ||||||||
| MiddleName: | |||||||||
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| Credential: | DIETICIAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 506 VEREDA DEL LAGO | ||||||||
| Address2: | LOS ARBOLES | ||||||||
| City: | CAROLINA | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009877132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7877522634 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1715 AVE PONCE DE LEON | ||||||||
| Address2: | HOSPITAL AUXILIO MUTUO, NUTRITION DEPARTMENT | ||||||||
| City: | SAN JUAN | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009091958 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7877582000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133N00000X | 969 | PR | Y | Dietary & Nutritional Service Providers | Nutritionist |
ID Information
| ID | Type | State | Issuer | Description | 969 | 01 | PR | DIETITIAN'S LICENSE | OTHER |