Provider Demographics
NPI:1790493344
Name:KLOPOTEK, NICOLE MARIE (CST-CERT SURG TECH)
Entity Type:Individual
Prefix:MISS
First Name:NICOLE
Middle Name:MARIE
Last Name:KLOPOTEK
Suffix:
Gender:F
Credentials:CST-CERT SURG TECH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8681 A C SKINNER PKWY APT 634
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-0846
Mailing Address - Country:US
Mailing Address - Phone:904-522-4144
Mailing Address - Fax:
Practice Address - Street 1:8681 A C SKINNER PKWY APT 634
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-0846
Practice Address - Country:US
Practice Address - Phone:904-522-4144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-14
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL148606246ZS0410X
343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist