Healthcare Provider Details

I. General information

NPI: 1710483029
Provider Name (Legal Business Name): NANICHI ALEXANDRA RAMOS ROLDAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2018
Last Update Date: 09/25/2024
Certification Date: 09/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 CIVIC CENTER BLVD
PHILADELPHIA PA
19104-4395
US

IV. Provider business mailing address

24C CALLE BARRANQUITAS
CAGUAS PR
00727-4950
US

V. Phone/Fax

Practice location:
  • Phone: 215-590-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number14837
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberTRN31182
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code2081P0010X
TaxonomyPediatric Rehabilitation Medicine Physician
License NumberMD485459
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: