1245864081 NPI number — MRS. RAQUEL IVELISSE LOPEZ CRESPO PSIC

Table of content: MRS. RAQUEL IVELISSE LOPEZ CRESPO PSIC (NPI 1245864081)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245864081 NPI number — MRS. RAQUEL IVELISSE LOPEZ CRESPO PSIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LOPEZ CRESPO
Provider First Name:
RAQUEL
Provider Middle Name:
IVELISSE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PSIC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245864081
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/17/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
VILLAS DE LOIZA
Provider Second Line Business Mailing Address:
CALLE 28A TT21
Provider Business Mailing Address City Name:
CANOVANAS
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00729
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
ENRIQUE MANGUAL CANOVANAS MALL
Provider Second Line Business Practice Location Address:
OFICINA LOCAL 14
Provider Business Practice Location Address City Name:
CANOVANAS
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00729
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-344-1277
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/02/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  6375 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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