Provider Demographics
NPI:1871980698
Name:AVILES WETHERELL, KATHELYNN JANESSE
Entity type:Individual
Prefix:
First Name:KATHELYNN
Middle Name:JANESSE
Last Name:AVILES WETHERELL
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 1:10 CALLE CASIA
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00921-3200
Mailing Address - Country:US
Mailing Address - Phone:787-641-7582
Mailing Address - Fax:787-641-4561
Practice Address - Street 1:10 CALLE CASIA
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00921-3200
Practice Address - Country:US
Practice Address - Phone:787-641-7582
Practice Address - Fax:787-641-4561
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-20
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PR21889208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program