Provider Demographics
NPI:1184638447
Name:DEITRICK, NICOLE A (LMT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:A
Last Name:DEITRICK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 25TH DR E
Mailing Address - Street 2:
Mailing Address - City:ELLENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34222-2053
Mailing Address - Country:US
Mailing Address - Phone:941-721-4559
Mailing Address - Fax:941-721-0142
Practice Address - Street 1:909 25TH DR E
Practice Address - Street 2:
Practice Address - City:ELLENTON
Practice Address - State:FL
Practice Address - Zip Code:34222-2053
Practice Address - Country:US
Practice Address - Phone:941-721-4559
Practice Address - Fax:941-721-0142
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA29664174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist