Provider Demographics
NPI:1417061979
Name:HOLMES, NICOLE NIKKIE (MASTERS)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:NIKKIE
Last Name:HOLMES
Suffix:
Gender:F
Credentials:MASTERS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1566 GUARDIAN CT
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32221-8035
Mailing Address - Country:US
Mailing Address - Phone:904-421-6011
Mailing Address - Fax:904-734-8378
Practice Address - Street 1:2354 UNIVERSITY BLVD N
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32211-3228
Practice Address - Country:US
Practice Address - Phone:904-421-6011
Practice Address - Fax:904-743-8378
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL7676816Medicaid