Provider Demographics
NPI:1982334892
Name:FRED, MARIANELA
Entity type:Individual
Prefix:
First Name:MARIANELA
Middle Name:
Last Name:FRED
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:URB SAN FERNANDO CALLE 15 C3
Mailing Address - Street 2:
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00957
Mailing Address - Country:US
Mailing Address - Phone:787-920-2080
Mailing Address - Fax:
Practice Address - Street 1:BARRIO MAVILLAS CARR 159 KM 16.7 #A3
Practice Address - Street 2:
Practice Address - City:COROZAL
Practice Address - State:PR
Practice Address - Zip Code:00783
Practice Address - Country:US
Practice Address - Phone:787-430-5899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-14
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2053306156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician