Provider Demographics
NPI:1508527748
Name:CAVIGNARO, NICOLE RUSSO
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:RUSSO
Last Name:CAVIGNARO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 FULLER POND RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:MA
Mailing Address - Zip Code:01949-2508
Mailing Address - Country:US
Mailing Address - Phone:978-930-0139
Mailing Address - Fax:
Practice Address - Street 1:1514 NIRA ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8652
Practice Address - Country:US
Practice Address - Phone:904-387-4991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-09
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9117532207N00000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology