Basic Information
| Provider Information | |||||||||
| NPI: | 1013640549 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NIEVES HERNANDEZ | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3898 VIA POINCIANA | ||||||||
| Address2: | |||||||||
| City: | LAKE WORTH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334672951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5615085993 | ||||||||
| FaxNumber: | 8444655537 | ||||||||
| Practice Location | |||||||||
| Address1: | 3898 VIA POINCIANA STE 12 | ||||||||
| Address2: | |||||||||
| City: | LAKE WORTH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334672951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5615085993 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2022 | ||||||||
| LastUpdateDate: | 07/01/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
No ID Information.