Healthcare Provider Details

I. General information

NPI: 1861339665
Provider Name (Legal Business Name): CAMILLE NICHOLE VEGA DE JESUS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2026
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 CALLE SANTA CRUZ
BAYAMON PR
00961-7052
US

IV. Provider business mailing address

PO BOX 552
GUAYAMA PR
00785-0552
US

V. Phone/Fax

Practice location:
  • Phone: 787-983-1818
  • Fax:
Mailing address:
  • Phone: 787-983-1818
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number17714
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: