Provider Demographics
NPI:1407244247
Name:OFFENBERG, NICOLE (MCMSC, PA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:OFFENBERG
Suffix:
Gender:F
Credentials:MCMSC, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 SW 1ST AVE
Mailing Address - Street 2:APT. 407
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33301-3476
Mailing Address - Country:US
Mailing Address - Phone:954-294-9193
Mailing Address - Fax:
Practice Address - Street 1:400 SW 1ST AVE
Practice Address - Street 2:APT. 407
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33301-3476
Practice Address - Country:US
Practice Address - Phone:954-294-9193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-01
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPAT9108441363A00000X
FLPA9108441363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant