Provider Demographics
NPI:1710337696
Name:DE PAZ, NICOLE CHANTAL (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:CHANTAL
Last Name:DE PAZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4033 TAMPA RD STE 101
Mailing Address - Street 2:
Mailing Address - City:OLDSMAR
Mailing Address - State:FL
Mailing Address - Zip Code:34677-3224
Mailing Address - Country:US
Mailing Address - Phone:813-854-2003
Mailing Address - Fax:813-436-5378
Practice Address - Street 1:6671 13TH AVE N STE 1D
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-5411
Practice Address - Country:US
Practice Address - Phone:727-381-1147
Practice Address - Fax:727-345-2489
Is Sole Proprietor?:No
Enumeration Date:2016-06-21
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME149199208000000X
MA267862208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics