Healthcare Provider Details

I. General information

NPI: 1972168342
Provider Name (Legal Business Name): NICOLE MAYRIM BAEZ MORALES MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2019
Last Update Date: 07/17/2020
Certification Date: 07/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

AVE.PONCE DE LEON 255 HATO REY
SAN JUAN PR
00916
US

IV. Provider business mailing address

PO BOX 723
FAJARDO PR
00738-0723
US

V. Phone/Fax

Practice location:
  • Phone: 787-758-2500
  • Fax:
Mailing address:
  • Phone: 787-435-3977
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number021755
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: