Provider Demographics
NPI:1003848037
Name:NIEVES, OMAYRA
Entity Type:Individual
Prefix:
First Name:OMAYRA
Middle Name:
Last Name:NIEVES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 CAMBRIDGEPARK DR APT 6115
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02140-2383
Mailing Address - Country:US
Mailing Address - Phone:617-877-5797
Mailing Address - Fax:
Practice Address - Street 1:30 CAMBRIDGEPARK DR APT 6115
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02140-2383
Practice Address - Country:US
Practice Address - Phone:617-877-5797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2210022084P0015X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0015XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychosomatic Medicine