Provider Demographics
NPI:1437414919
Name:NICOLAS, ANNE-MARIE CAROLINE
Entity Type:Individual
Prefix:DR
First Name:ANNE-MARIE
Middle Name:CAROLINE
Last Name:NICOLAS
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:ANNE-MARIE
Other - Middle Name:CAROLINE
Other - Last Name:NICOLAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:600 KINGSMILL CV
Mailing Address - Street 2:#210
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-5839
Mailing Address - Country:US
Mailing Address - Phone:407-314-6114
Mailing Address - Fax:
Practice Address - Street 1:4404 S FLORIDA AVE
Practice Address - Street 2:SUITE #3
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-2169
Practice Address - Country:US
Practice Address - Phone:863-709-8110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-10
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY8211103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical