Provider Demographics
NPI:1821353004
Name:NICOLO, SAGE EMIL (LPN)
Entity Type:Individual
Prefix:
First Name:SAGE
Middle Name:EMIL
Last Name:NICOLO
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5213 RESEDA DR
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34652-6275
Mailing Address - Country:US
Mailing Address - Phone:404-405-1741
Mailing Address - Fax:
Practice Address - Street 1:15116 MESA DR
Practice Address - Street 2:APT 725
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77396-2394
Practice Address - Country:US
Practice Address - Phone:734-837-5481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-12
Last Update Date:2017-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX226086164W00000X
FLPN5226139164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse