Healthcare Provider Details

I. General information

NPI: 1275038036
Provider Name (Legal Business Name): ENID YADIRA NIEVES ANDRADES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2018
Last Update Date: 04/12/2023
Certification Date: 04/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1887 SE PORT ST LUCIE BLVD
PORT ST LUCIE FL
34952-5530
US

IV. Provider business mailing address

5064 BRILLIANCE CIR
COCOA FL
32926-2493
US

V. Phone/Fax

Practice location:
  • Phone: 771-463-0444
  • Fax: 772-219-1339
Mailing address:
  • Phone: 787-806-7242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: