Provider Demographics
NPI:1447976683
Name:MONCLOVA RODRIGUEZ, CRYSTAL MARIE (LND, CMGI, CND)
Entity type:Individual
Prefix:MS
First Name:CRYSTAL
Middle Name:MARIE
Last Name:MONCLOVA RODRIGUEZ
Suffix:
Gender:F
Credentials:LND, CMGI, CND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:URB. METROPOLIS STREET 46
Mailing Address - Street 2:2T21
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00987
Mailing Address - Country:US
Mailing Address - Phone:787-449-8248
Mailing Address - Fax:
Practice Address - Street 1:2016 AVE BORINQUEN
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00915-3823
Practice Address - Country:US
Practice Address - Phone:787-919-3961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-19
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2171133V00000X, 133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered