Healthcare Provider Details

I. General information

NPI: 1003700428
Provider Name (Legal Business Name): NILDA IVELISSE ACEVEDO HERNANDEZ MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2025
Last Update Date: 06/09/2025
Certification Date: 05/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 1106
MOCA PR
00676-1106
US

IV. Provider business mailing address

URB. ISLAZUL 3379 CALLE TENERIFE
ISABELA PR
00662
US

V. Phone/Fax

Practice location:
  • Phone: 939-200-3629
  • Fax:
Mailing address:
  • Phone: 787-224-0664
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number8083
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: