Provider Demographics
NPI:1578248522
Name:DELLA PORTA, NICOLE ANN (AA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANN
Last Name:DELLA PORTA
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 N OCEAN BLVD # Q204
Mailing Address - Street 2:
Mailing Address - City:BRINY BREEZES
Mailing Address - State:FL
Mailing Address - Zip Code:33435-7341
Mailing Address - Country:US
Mailing Address - Phone:561-634-1387
Mailing Address - Fax:
Practice Address - Street 1:2601 S BLAIR STONE RD STE GC3
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32301-5939
Practice Address - Country:US
Practice Address - Phone:850-385-0144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-19
Last Update Date:2024-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAA885367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant