Provider Demographics
NPI:1104638097
Name:RODRIGUEZ, LIDIETTE MARIE (RDN)
Entity type:Individual
Prefix:
First Name:LIDIETTE
Middle Name:MARIE
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 74 BOX 6669
Mailing Address - Street 2:
Mailing Address - City:CAYEY
Mailing Address - State:PR
Mailing Address - Zip Code:00736-9111
Mailing Address - Country:US
Mailing Address - Phone:787-390-0487
Mailing Address - Fax:
Practice Address - Street 1:2 CALLE BELLA VISTA
Practice Address - Street 2:
Practice Address - City:MANATI
Practice Address - State:PR
Practice Address - Zip Code:00674
Practice Address - Country:US
Practice Address - Phone:787-390-0487
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-27
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1890133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered