Provider Demographics
NPI:1902016231
Name:NIEVES, IVELISSE
Entity Type:Individual
Prefix:
First Name:IVELISSE
Middle Name:
Last Name:NIEVES
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 1:26 CARR 833
Mailing Address - Street 2:406-J LA VILLA GARDEN APT.
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00971-9001
Mailing Address - Country:US
Mailing Address - Phone:787-409-9154
Mailing Address - Fax:
Practice Address - Street 1:47 AVE ESMERALDA
Practice Address - Street 2:URB MUNOZ RIVERA
Practice Address - City:GUAYNABO
Practice Address - State:PR
Practice Address - Zip Code:00969-4429
Practice Address - Country:US
Practice Address - Phone:787-720-7439
Practice Address - Fax:787-790-3925
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3289183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist