Provider Demographics
NPI:1831468586
Name:SMITH, NICOLE D (LMT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:D
Last Name:SMITH
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6015 CHESTER CIR STE 206
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32217-2273
Mailing Address - Country:US
Mailing Address - Phone:904-365-8305
Mailing Address - Fax:
Practice Address - Street 1:6015 CHESTER CIR STE 206
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-2273
Practice Address - Country:US
Practice Address - Phone:904-365-8305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-27
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA27835225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist