MEDICARE: NICOLE VANESSA NIETO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1376385542
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE VANESSA NIETO

Provider Business Mailing Address
First Line	:	2328 10TH AVE N STE 603
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33461-6606
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2328 10TH AVE N STE 603
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33461-6606
Country	:	US
Telephone Number	:	561-693-4121
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/10/2024
Last Update Date	:	06/10/2024

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Directions to “ NICOLE VANESSA NIETO ” Practice Location

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