Provider Demographics
NPI:1578820692
Name:FAWKES, NICOLE A
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:A
Last Name:FAWKES
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 1:3080 QUANTUM LAKES DR
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33426-8334
Mailing Address - Country:US
Mailing Address - Phone:561-859-7954
Mailing Address - Fax:
Practice Address - Street 1:3080 QUANTUM LAKES DR
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33426-8334
Practice Address - Country:US
Practice Address - Phone:561-859-7954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-13
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator