Provider Demographics
NPI:1316120348
Name:LLANOS, WANDA I (RD)
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:I
Last Name:LLANOS
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:PO BOX 9108
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00908-0108
Mailing Address - Country:US
Mailing Address - Phone:787-640-5721
Mailing Address - Fax:
Practice Address - Street 1:CALLE AMERICO SALAS #1452 (ALTOS), PDA 22
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00910
Practice Address - Country:US
Practice Address - Phone:787-640-5721
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-13
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1432133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist