Provider Demographics
NPI:1659843423
Name:DE ST. AUBIN, NICOLE DANIELLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:DANIELLE
Last Name:DE ST. AUBIN
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 1:7804 41ST AVE E
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34211-9519
Mailing Address - Country:US
Mailing Address - Phone:941-565-6032
Mailing Address - Fax:
Practice Address - Street 1:5741 BEE RIDGE RD STE 350
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34233-5082
Practice Address - Country:US
Practice Address - Phone:941-366-8810
Practice Address - Fax:941-366-8812
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-18
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA47349225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist