Provider Demographics
NPI:1538726831
Name:IRIZARRY TALAVERA, NELLY IVETTE
Entity type:Individual
Prefix:
First Name:NELLY
Middle Name:IVETTE
Last Name:IRIZARRY TALAVERA
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:PO BOX 141867
Mailing Address - Street 2:
Mailing Address - City:ARECIBO
Mailing Address - State:PR
Mailing Address - Zip Code:00614-1867
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:CALLE HERNANDEZ CARRION URB ATENAS
Practice Address - Street 2:DEPTO EDUCACION MEDICA
Practice Address - City:MANATI
Practice Address - State:PR
Practice Address - Zip Code:00674
Practice Address - Country:US
Practice Address - Phone:787-621-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-22
Last Update Date:2020-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR14959390200000X
PR21727208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program