Provider Demographics
NPI:1477166627
Name:SMITH, NICOLE (APRN, FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:APRN, FNP-BC
Other - Prefix:MISS
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:GUETTLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN, FNP-BC
Mailing Address - Street 1:PO BOX 102222
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-2222
Mailing Address - Country:US
Mailing Address - Phone:239-274-8200
Mailing Address - Fax:
Practice Address - Street 1:3730 7TH TER STE 101
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-6556
Practice Address - Country:US
Practice Address - Phone:772-581-0528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-27
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN110649200363L00000X
FLAPRN11008747363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110649200Medicaid