Healthcare Provider Details

I. General information

NPI: 1568203776
Provider Name (Legal Business Name): NICOLE MARIE BRACERO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2024
Last Update Date: 06/03/2024
Certification Date: 05/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CALLE MANUEL F. ROSSI ESQ. ISABEL II VARMED HEALTH CENTER BUILDING B
BAYAMON PR
00960
US

IV. Provider business mailing address

PO BOX 55098
BAYAMON PR
00960-4098
US

V. Phone/Fax

Practice location:
  • Phone: 787-988-2027
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2263
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: