Provider Demographics
NPI:1316557630
Name:FELTON, NICOLE FELICIA
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:FELICIA
Last Name:FELTON
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 1:9267 CANARY IVY LN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32219-6001
Mailing Address - Country:US
Mailing Address - Phone:904-535-8218
Mailing Address - Fax:
Practice Address - Street 1:9267 CANARY IVY LN
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32219-6001
Practice Address - Country:US
Practice Address - Phone:904-535-8218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-01
Last Update Date:2020-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental DisabilitiesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL203642802Medicaid