Provider Demographics
NPI:1023661196
Name:NIETO, JAZZY-MAE
Entity type:Individual
Prefix:
First Name:JAZZY-MAE
Middle Name:
Last Name:NIETO
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 1:6401 S WEST SHORE BLVD APT 1403
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33616-1395
Mailing Address - Country:US
Mailing Address - Phone:719-569-1757
Mailing Address - Fax:
Practice Address - Street 1:3250 ZEMKE AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33621-5023
Practice Address - Country:US
Practice Address - Phone:813-827-9870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-18
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians