Provider Demographics
NPI:1760703995
Name:NICOPHENE, NICOLE (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:NICOPHENE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4780 SW 64TH AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33314-4400
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:350 N PINE ISLAND RD STE 200
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-1849
Practice Address - Country:US
Practice Address - Phone:954-424-4321
Practice Address - Fax:954-959-8055
Is Sole Proprietor?:No
Enumeration Date:2010-06-22
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME-113823207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009090000Medicaid
14R3KOtherFLORIDA BLUE
14R3KOtherFLORIDA BLUE