Provider Demographics
NPI:1548544729
Name:FONSECA, LIZA V
Entity type:Individual
Prefix:
First Name:LIZA
Middle Name:V
Last Name:FONSECA
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:A1 CALLE YUNQUECITO
Mailing Address - Street 2:URB LOMAS DE CAROLINA
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00987-7329
Mailing Address - Country:US
Mailing Address - Phone:787-757-3300
Mailing Address - Fax:
Practice Address - Street 1:A2 YUNQUECITO
Practice Address - Street 2:
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00987-7329
Practice Address - Country:US
Practice Address - Phone:787-757-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-05
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR668174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist