Provider Demographics
NPI:1033654843
Name:DEVLIEGER, NICOLE A
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:A
Last Name:DEVLIEGER
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 1:11526 LEDA LN
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34654-6237
Mailing Address - Country:US
Mailing Address - Phone:727-265-0995
Mailing Address - Fax:
Practice Address - Street 1:4539 S DALE MABRY HWY STE 110
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33611
Practice Address - Country:US
Practice Address - Phone:813-250-1208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-03
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL48992255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
7272650995OtherPHONE