Provider Demographics
NPI:1275735979
Name:NIEVES, LISSETTE AVILES
Entity Type:Individual
Prefix:
First Name:LISSETTE
Middle Name:AVILES
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:URB. MONTE CASINO
Mailing Address - Street 2:CALLE ALMACIGO # 261
Mailing Address - City:TOA ALTA
Mailing Address - State:PR
Mailing Address - Zip Code:00953
Mailing Address - Country:US
Mailing Address - Phone:787-251-5356
Mailing Address - Fax:
Practice Address - Street 1:CPETE CLINICA INMUNOLOGICA DE CENTRO MEDICO
Practice Address - Street 2:BO. MONCAILLOS PASEO BARBOSA
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00936
Practice Address - Country:US
Practice Address - Phone:787-754-8118
Practice Address - Fax:787-754-8127
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4542183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician