Provider Demographics
NPI:1679045330
Name:GRESS, NICOLE LYNN (CNM)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYNN
Last Name:GRESS
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 748817
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-8817
Mailing Address - Country:US
Mailing Address - Phone:813-286-0333
Mailing Address - Fax:813-282-1806
Practice Address - Street 1:301 HEALTH PARK BLVD STE 219
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5795
Practice Address - Country:US
Practice Address - Phone:904-819-9898
Practice Address - Fax:904-819-9594
Is Sole Proprietor?:No
Enumeration Date:2018-12-19
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11011386363LW0102X, 367A00000X, 367A00000X
NDR40191367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health