Provider Demographics
NPI:1396400073
Name:VIERA JIMENEZ, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:VIERA JIMENEZ
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 1:4 CALLE GRAN CANARIA
Mailing Address - Street 2:
Mailing Address - City:LAS PIEDRAS
Mailing Address - State:PR
Mailing Address - Zip Code:00771-3075
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17000 CARR 3
Practice Address - Street 2:
Practice Address - City:CANOVANAS
Practice Address - State:PR
Practice Address - Zip Code:00729-2881
Practice Address - Country:US
Practice Address - Phone:787-957-8050
Practice Address - Fax:787-957-8049
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-08
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PR80031835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program