Healthcare Provider Details

I. General information

NPI: 1811851959
Provider Name (Legal Business Name): NICOLE M FOURQUET DRA.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2025
Last Update Date: 12/12/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1123 AVE HOSTOS
PONCE PR
00717-0952
US

IV. Provider business mailing address

URB. VEREDAS DE YAUCO, CALLE SENDERO #104
YAUCO PR
00698
US

V. Phone/Fax

Practice location:
  • Phone: 787-637-1408
  • Fax:
Mailing address:
  • Phone: 787-637-1408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number8722
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number8722
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: