Provider Demographics
NPI:1508541327
Name:SOTO MALDONADO, NICOLLE (MD)
Entity Type:Individual
Prefix:
First Name:NICOLLE
Middle Name:
Last Name:SOTO MALDONADO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60327
Mailing Address - Street 2:
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00960-6032
Mailing Address - Country:US
Mailing Address - Phone:787-787-5151
Mailing Address - Fax:
Practice Address - Street 1:100 AVE LAUREL
Practice Address - Street 2:
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00956-4816
Practice Address - Country:US
Practice Address - Phone:787-787-5151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-19
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6142935390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program