Provider Demographics
NPI:1043666340
Name:DE LATORRE, EDNA (LND)
Entity type:Individual
Prefix:
First Name:EDNA
Middle Name:
Last Name:DE LATORRE
Suffix:
Gender:F
Credentials:LND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 VIA AVENTURA APT 7710
Mailing Address - Street 2:COND AVENTURA
Mailing Address - City:TRUJILLO ALTO
Mailing Address - State:PR
Mailing Address - Zip Code:00976-6191
Mailing Address - Country:US
Mailing Address - Phone:618-803-1818
Mailing Address - Fax:
Practice Address - Street 1:350 VIA AVENTURA APT 7710
Practice Address - Street 2:CONDOMINIO AVENTURA
Practice Address - City:TRUJILLO ALTO
Practice Address - State:PR
Practice Address - Zip Code:00976-6191
Practice Address - Country:US
Practice Address - Phone:618-803-1818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-05
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1009133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1009Other1009