Provider Demographics
NPI:1265043392
Name:IBANEZ, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:IBANEZ
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 1:121 N HIGHLAND ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-5764
Mailing Address - Country:US
Mailing Address - Phone:352-720-5194
Mailing Address - Fax:407-386-7133
Practice Address - Street 1:1590 TROPIC PARK DR
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32773-6323
Practice Address - Country:US
Practice Address - Phone:407-202-2220
Practice Address - Fax:407-369-4307
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-12
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician