Provider Demographics
NPI:1467064709
Name:NIETO, VICTORIA ROSE (OPHTHALMIC DISPENSER)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:ROSE
Last Name:NIETO
Suffix:
Gender:F
Credentials:OPHTHALMIC DISPENSER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:639 VETERANS RD W
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10309-1159
Mailing Address - Country:US
Mailing Address - Phone:347-530-2403
Mailing Address - Fax:718-966-9404
Practice Address - Street 1:199 MAIN ST
Practice Address - Street 2:
Practice Address - City:KEANSBURG
Practice Address - State:NJ
Practice Address - Zip Code:07734-1768
Practice Address - Country:US
Practice Address - Phone:347-530-2403
Practice Address - Fax:718-966-9404
Is Sole Proprietor?:No
Enumeration Date:2020-08-18
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009771156FX1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1100XEye and Vision Services ProvidersTechnician/TechnologistOphthalmic