Provider Demographics
NPI:1710497300
Name:KABLAOUI, NOUR (AA)
Entity Type:Individual
Prefix:
First Name:NOUR
Middle Name:
Last Name:KABLAOUI
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8451 GATE PKWY W APT 1331
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-4107
Mailing Address - Country:US
Mailing Address - Phone:651-786-9998
Mailing Address - Fax:
Practice Address - Street 1:820 PRUDENTIAL DR STE 606
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8208
Practice Address - Country:US
Practice Address - Phone:904-398-3356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-09
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAA423367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist AssistantGroup - Single Specialty