Provider Demographics
NPI:1346845039
Name:CARDIELLO, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:CARDIELLO
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 1:10250 SE 167TH PLACE RD UNIT 5
Mailing Address - Street 2:
Mailing Address - City:SUMMERFIELD
Mailing Address - State:FL
Mailing Address - Zip Code:34491-8682
Mailing Address - Country:US
Mailing Address - Phone:352-307-9925
Mailing Address - Fax:352-307-8442
Practice Address - Street 1:1801 US HIGHWAY 441 BLDG 100
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-2545
Practice Address - Country:US
Practice Address - Phone:352-460-4004
Practice Address - Fax:352-460-4003
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-01
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11010407363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL109304300Medicaid