Provider Demographics
NPI:1497164289
Name:VARGAS ORTIZ, NICOLE NAOMY SR
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:NAOMY
Last Name:VARGAS ORTIZ
Suffix:SR
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:U417 CALLE NICARAGUA
Mailing Address - Street 2:URB. ROLLING HILLS
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00987
Mailing Address - Country:US
Mailing Address - Phone:939-218-1356
Mailing Address - Fax:
Practice Address - Street 1:759 AVELINO VICENTE
Practice Address - Street 2:SANTURCE
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00909
Practice Address - Country:US
Practice Address - Phone:787-303-9662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-06
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1058224Z00000X
PR917224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR8002703478400OtherTRIPLE-S