Provider Demographics
NPI:1891780037
Name:NIEVES-MORENO, WANDA IVELISSE (DC)
Entity Type:Individual
Prefix:DR
First Name:WANDA
Middle Name:IVELISSE
Last Name:NIEVES-MORENO
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:654 E BLOOMINGDALE AVE
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-8111
Mailing Address - Country:US
Mailing Address - Phone:813-685-5200
Mailing Address - Fax:813-654-8758
Practice Address - Street 1:654 E BLOOMINGDALE AVE
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-8111
Practice Address - Country:US
Practice Address - Phone:813-685-5200
Practice Address - Fax:813-654-8758
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8811111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL381946900Medicaid
FLU6011ZOtherMEDICARE PTAN
FLU6011ZOtherMEDICARE PTAN
FLU6011Medicare PIN