Provider Demographics
NPI:1720267701
Name:CANDELARIA, CLARISOL (LND)
Entity type:Individual
Prefix:MRS
First Name:CLARISOL
Middle Name:
Last Name:CANDELARIA
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 1:200 AVE. R. CORDERO, STE. 140
Mailing Address - Street 2:PMB 248
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00725-3757
Mailing Address - Country:US
Mailing Address - Phone:787-307-0054
Mailing Address - Fax:787-474-0948
Practice Address - Street 1:CALLE 27 AA-1 #4
Practice Address - Street 2:BAIROA
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00725
Practice Address - Country:US
Practice Address - Phone:787-307-0054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-26
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1143133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered