Provider Demographics
NPI:1750490819
Name:NEIDHART, NICOLE MARIE (ARNP, CNM)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:NEIDHART
Suffix:
Gender:F
Credentials:ARNP, CNM
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:MARIE
Other - Last Name:THOMASNEIDHART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP, CNM
Mailing Address - Street 1:PO BOX 1506
Mailing Address - Street 2:
Mailing Address - City:CALLAHAN
Mailing Address - State:FL
Mailing Address - Zip Code:32011-1506
Mailing Address - Country:US
Mailing Address - Phone:904-424-7206
Mailing Address - Fax:
Practice Address - Street 1:915 W MONROE ST STE 100
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-1177
Practice Address - Country:US
Practice Address - Phone:904-518-1398
Practice Address - Fax:904-394-2811
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3317462367A00000X, 363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAD842YMedicare PIN