Provider Demographics
NPI:1437868403
Name:CETOUTE, NICKENSON (APRN)
Entity Type:Individual
Prefix:
First Name:NICKENSON
Middle Name:
Last Name:CETOUTE
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3287 SUGAR BERRY WAY
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32303-7371
Mailing Address - Country:US
Mailing Address - Phone:786-704-7952
Mailing Address - Fax:
Practice Address - Street 1:7000 H C KELLEY RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32831-2518
Practice Address - Country:US
Practice Address - Phone:407-207-7777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-18
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11022673363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner