Provider Demographics
NPI:1174341788
Name:RODRIGUEZ, LYVIAN LYNETTE
Entity type:Individual
Prefix:
First Name:LYVIAN
Middle Name:LYNETTE
Last Name:RODRIGUEZ
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 1:831 CALLE SAUCO
Mailing Address - Street 2:
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00716-2124
Mailing Address - Country:US
Mailing Address - Phone:787-298-0475
Mailing Address - Fax:
Practice Address - Street 1:831 CALLE SAUCO
Practice Address - Street 2:
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00716-2124
Practice Address - Country:US
Practice Address - Phone:787-298-0475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-02
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR000658363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant