Provider Demographics
NPI:1609346378
Name:RODRIGUEZ, NICOLE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4106 W LAKE MARY BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-3315
Mailing Address - Country:US
Mailing Address - Phone:407-333-2503
Mailing Address - Fax:
Practice Address - Street 1:4106 W LAKE MARY BLVD
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-3315
Practice Address - Country:US
Practice Address - Phone:407-333-2503
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-26
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9399156363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner