Provider Demographics
NPI:1982198909
Name:REDONDO, NICOLE BORREGO
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:BORREGO
Last Name:REDONDO
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 1:15621 SW 31ST LN
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33185-5905
Mailing Address - Country:US
Mailing Address - Phone:305-978-2702
Mailing Address - Fax:
Practice Address - Street 1:4300 ALTON RD
Practice Address - Street 2:
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33140-2948
Practice Address - Country:US
Practice Address - Phone:305-674-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-22
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program