Provider Demographics
NPI:1215679733
Name:FONTANEZ DE JESUS, AMARILIS (LND)
Entity type:Individual
Prefix:MRS
First Name:AMARILIS
Middle Name:
Last Name:FONTANEZ DE JESUS
Suffix:
Gender:F
Credentials:LND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:F-4 CALLE GUATIBIRI
Mailing Address - Street 2:URB. VILLA BORINQUEN
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00725
Mailing Address - Country:US
Mailing Address - Phone:787-473-0222
Mailing Address - Fax:
Practice Address - Street 1:F-4 CALLE GUATIBIRI
Practice Address - Street 2:URB. VILLA BORINQUEN
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00725
Practice Address - Country:US
Practice Address - Phone:787-473-0222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-13
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1933133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Single Specialty