Provider Demographics
NPI:1003131707
Name:MEDERO, NITZA (LIC)
Entity Type:Individual
Prefix:
First Name:NITZA
Middle Name:
Last Name:MEDERO
Suffix:
Gender:F
Credentials:LIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:158 CALLE CEDRO
Mailing Address - Street 2:URB LOS ROBLES
Mailing Address - City:MOCA
Mailing Address - State:PR
Mailing Address - Zip Code:00676-4213
Mailing Address - Country:US
Mailing Address - Phone:939-717-0069
Mailing Address - Fax:787-823-4306
Practice Address - Street 1:158 CALLE CEDRO
Practice Address - Street 2:URB LOS ROBLES
Practice Address - City:MOCA
Practice Address - State:PR
Practice Address - Zip Code:00676-4213
Practice Address - Country:US
Practice Address - Phone:939-717-0069
Practice Address - Fax:787-823-4306
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-06
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1047174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1047OtherSTATE LICENCE