Provider Demographics
NPI:1073252862
Name:BETANCOURT, FABIOLA MICHELLE
Entity type:Individual
Prefix:
First Name:FABIOLA
Middle Name:MICHELLE
Last Name:BETANCOURT
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:VALLE ESCONDIDO 232 MIOSOTIS
Mailing Address - Street 2:
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00987
Mailing Address - Country:US
Mailing Address - Phone:787-564-0636
Mailing Address - Fax:
Practice Address - Street 1:1115 AVE 65 INFANTERIA
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00924-3489
Practice Address - Country:US
Practice Address - Phone:787-768-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-01
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR8270183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist