Provider Demographics
NPI:1174724843
Name:RIVERA CRUZ, JEANNETE (LIC)
Entity type:Individual
Prefix:MRS
First Name:JEANNETE
Middle Name:
Last Name:RIVERA CRUZ
Suffix:
Gender:F
Credentials:LIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PMB 509
Mailing Address - Street 2:P.O.BOX 7891
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00970-7891
Mailing Address - Country:US
Mailing Address - Phone:787-789-1919
Mailing Address - Fax:787-789-1921
Practice Address - Street 1:CASA LINA AVE. #1 SUITE 101
Practice Address - Street 2:177 ROUTE LOS FILTROS
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00969
Practice Address - Country:US
Practice Address - Phone:787-789-1919
Practice Address - Fax:787-789-1921
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133NN1002X
PR964133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education