Provider Demographics
NPI:1821327735
Name:YATES, NICOLE MICHELLE (SLP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MICHELLE
Last Name:YATES
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11864 CRESTRIDGE LOOP
Mailing Address - Street 2:
Mailing Address - City:TRINITY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-0018
Mailing Address - Country:US
Mailing Address - Phone:813-944-9594
Mailing Address - Fax:
Practice Address - Street 1:11864 CRESTRIDGE LOOP
Practice Address - Street 2:
Practice Address - City:TRINITY
Practice Address - State:FL
Practice Address - Zip Code:34655-0018
Practice Address - Country:US
Practice Address - Phone:813-944-9594
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-24
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA10890235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001700700Medicaid