Provider Demographics
NPI:1588674576
Name:FANARJIAN, NICOLE J (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:J
Last Name:FANARJIAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2919 W SWANN AVE STE 303
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-4051
Mailing Address - Country:US
Mailing Address - Phone:813-569-0740
Mailing Address - Fax:813-864-7603
Practice Address - Street 1:2919 W SWANN AVE STE 303
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-4051
Practice Address - Country:US
Practice Address - Phone:813-569-0740
Practice Address - Fax:813-864-7603
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME107878207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5905150Medicaid
NC5905150Medicaid