Provider Demographics
NPI:1689045809
Name:NIEVES, WILFREDO (RN)
Entity Type:Individual
Prefix:
First Name:WILFREDO
Middle Name:
Last Name:NIEVES
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 N DAVIS RD
Mailing Address - Street 2:APT 511
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30241
Mailing Address - Country:US
Mailing Address - Phone:407-314-6625
Mailing Address - Fax:
Practice Address - Street 1:140 N DAVIS RD
Practice Address - Street 2:APT 511
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30241-1596
Practice Address - Country:US
Practice Address - Phone:407-314-6625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-14
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR37289163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALPPA809076294OtherBLUE CROSS BLUE SHIELD