Provider Demographics
NPI:1679339832
Name:PETITE, NICOLE MARIE (APRN)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:PETITE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7191 RIDGE CREEK TRL
Mailing Address - Street 2:
Mailing Address - City:SHAKOPEE
Mailing Address - State:MN
Mailing Address - Zip Code:55379-5524
Mailing Address - Country:US
Mailing Address - Phone:612-817-7982
Mailing Address - Fax:
Practice Address - Street 1:3345 BURNS RD STE 302
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410-4321
Practice Address - Country:US
Practice Address - Phone:561-622-7661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-26
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11031468363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily