Provider Demographics
NPI:1972168342
Name:BAEZ MORALES, NICOLE MAYRIM (MD)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:MAYRIM
Last Name:BAEZ MORALES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 723
Mailing Address - Street 2:
Mailing Address - City:FAJARDO
Mailing Address - State:PR
Mailing Address - Zip Code:00738-0723
Mailing Address - Country:US
Mailing Address - Phone:787-435-3977
Mailing Address - Fax:
Practice Address - Street 1:AVE.PONCE DE LEON 255
Practice Address - Street 2:HATO REY
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00916
Practice Address - Country:US
Practice Address - Phone:787-758-2500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-01
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PR021755208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program