Provider Demographics
NPI:1710764253
Name:LAFAILLE, NICOLE CAROLYN
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:CAROLYN
Last Name:LAFAILLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11820 SAGEBRUSH CT
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-3647
Mailing Address - Country:US
Mailing Address - Phone:850-533-5626
Mailing Address - Fax:
Practice Address - Street 1:11820 SAGEBRUSH CT
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-3647
Practice Address - Country:US
Practice Address - Phone:850-533-5626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-08
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty