Healthcare Provider Details

I. General information

NPI: 1053560862
Provider Name (Legal Business Name): NINA M. VEGA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2008
Last Update Date: 05/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

472 AVE TITO CASTRO STE 401
PONCE PR
00716-4705
US

IV. Provider business mailing address

472 AVE TITO CASTRO STE 401
PONCE PR
00716-4705
US

V. Phone/Fax

Practice location:
  • Phone: 787-848-7646
  • Fax: 787-290-7722
Mailing address:
  • Phone: 787-848-7646
  • Fax: 787-290-7722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number18207
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number18207
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: