Provider Demographics
NPI:1699826446
Name:WELLS, NICOLE RENE (ARNP)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:RENE
Last Name:WELLS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:MRS
Other - First Name:NICOLE
Other - Middle Name:RENE
Other - Last Name:WELLS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ARNP
Mailing Address - Street 1:303 N CLYDE MORRIS BLVD
Mailing Address - Street 2:10TH FLOOR EAST, PBFS DEPT
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-2709
Mailing Address - Country:US
Mailing Address - Phone:386-226-4542
Mailing Address - Fax:386-239-2354
Practice Address - Street 1:303 N CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2709
Practice Address - Country:US
Practice Address - Phone:386-254-4000
Practice Address - Fax:386-322-4720
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2749562363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004077000Medicaid
FL004077000Medicaid