Provider Demographics
NPI:1124109509
Name:ROMAN, MAYRA LUZ (RD)
Entity type:Individual
Prefix:MRS
First Name:MAYRA
Middle Name:LUZ
Last Name:ROMAN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:SAGITARIO
Mailing Address - Street 2:FM 12 IRLANDA HEIGHTS
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00956
Mailing Address - Country:US
Mailing Address - Phone:787-641-7582
Mailing Address - Fax:
Practice Address - Street 1:CASIA
Practice Address - Street 2:20
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00927
Practice Address - Country:US
Practice Address - Phone:787-641-7582
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1193133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered